HospitalInspections.org

Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to identify and control the potential spread of infections by following infection control principles and policies. The deficient practice affected one of one handling of trash from a patient room with the patient in isolation for an infectious disease.

Findings included:

- Staff H, observed on 10/6/10 at 9:15am wore a protective apron and glove and entered a contact isolation room. Staff H removed the bagged trash and placed the bagged trash in a wheeled transportation bin. Staff H then pushed the bin throughout the hospital to the exit near the trash dumpster. Staff H continued to wear the same gloves and apron, reached into the wheeled bin and removed the bagged trash. Staff H then pushed the wheeled bin to the cafeteria. Staff H entered the food serving area and removed the bagged trash while wearing the same protective gloves. Staff H then emptied the bagged trash from the trash can near the dish return window. Staff H removed additional loose (unbagged) trash from the bottom of the trash can by reaching into the trash can with the gloved hands. Staff H then placed the trash bags in the transportation bin and moved to another area of the CAH. Staff H failed to remove the protective gloves and perform hand hygiene after exiting the patient's isolation room and failed to remove the protective gloves and perform hand hygiene prior to entering the food serving area.

- The hand hygiene policy, reviewed on 10/7/10, directed staff to wear protective gloves when there is the potential to contact infectious material including trash. The policy failed to direct staff to perform hand hygiene after contact with potentially infectious items.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop an individualized care plan to meet the care needs of 3 of 3 newborn patients (patient #'s 5, 7 and 9). The CAH failed to review and/or update the care plan for 13 of 13 patients admitted to the CAH (#'s 1, 2, 3, 10, 11, 12, 13, 15, 16, 17, 18, 19 and 20).

Findings included:

- Review on 10/5/10 of the closed medical record of patient #5 revealed an admission date of 7/28/10 with a diagnosis of birth by cesarean section. The medical record lacked evidence the nursing staff developed a care plan for the patient's care needs. Staff B and F, interviewed on 10/5/10 at 10:20am, confirmed the CAH failed to develop a care plan used to guide patient care. The CAH discharged patient #5 on 7/29/10.

- Review on 10/5/10 of the closed medical record of patient #7 revealed an admission date of 8/27/10 with a diagnosis of birth by cesarean section and underweight infant. The medical record lacked evidence the nursing staff developed a care plan for the patient's care needs. Staff B and F, interviewed on 10/5/10 at 10:20am, confirmed the CAH failed to develop a care plan used to guide patient care. The CAH discharged patient #7 on 9/1/10.

- The closed medical record of patient #9, reviewed on 10/5/10, revealed an admission date of 9/14/10 with a diagnosis of birth by cesarean section and elevated bilirubin. The medical record lacked evidence the nursing staff developed a care plan for the patient's care needs. Staff B and F, interviewed on 10/5/10 at 10:20am, confirmed the CAH failed to develop a care plan used to guide patient care. The CAH discharged patient #9 on 9/16/10.

- Review on 10/5/10 of the closed record for patient #1 revealed an admission date of 8/20/10 to a swing bed at the CAH for treatment of severe peripheral vascular disease, osteomyelitis, left below the knee amputation, history of congestive heart failure and aspiration pneumonia, chronic renal problems, diabetes, etc. congestive heart failure exacerbation (flair up), upper respiratory infection, hyperkalemia (high blood/potassium levels), pleural effusion, diabetes, etc. patient #1 ws transferred to another hospital on 8/23/10.
The care plan, created on 8/20/10, addresses the patient's activity tolerance, pain management, discharge planning risk for falls, potential for fluid balance problems, breathing problems, infections, teaching opportunities, physical mobility concerns,, potential for dietary concerns, potential for depression, self care deficit, skin integrity problems and urinary tract problems. Observation and interview patient #1 on 10/4/10 revealed the patient could not make reposition his/her body except for moving their hand, the patient reported significant discomfort, the patient could not take food/fluids orally and had a feeding tube placed for nutrition and fluids. Patient #1 also had physician orders for specialized respiratory care. Staff B, interviewed on 10/5/10 at 10:20am, confirmed the plan of care lacked patient specific information to direct staff in patient care. Staff B revealed the care plan is created upon admission and the staff lack knowledge of how or when to review and update the plan of care.

- The clinical record revealed admission orders for patient #1 with orders for "Acapella (a respiratory treatment) q1H (every one hour) while awake- please help patient with this". The clinical record revealed respiratory therapy assisted the patient with the treatment four times a day and provided four of the every hour while awake treatments. the care plan lacked documentation of coordination the of services provided by respiratory therapy and nursing to assure the patient received the treatment every hour while awake as ordered by the physician. The clinical documentation lacked evidence of nursing staff assisting the patient with the respiratory treatment during hospitalization. A chest x-ray, performed on 8/23/10 revealed a respiratory complication. The CAH transferred patient #1 to another hospital on 8/23/10 for the respiratory complications. Staff B, interviewed on 10/6/10 at 2:30pm confirmed the clinical record lacked documentation of the coordination of services to provide the ordered patient care. Staff B also confirmed the lack of documentation of the completion of the treatment as ordered.

- The clinical record for patient #17, revealed the CAH admitted the patient on 8/10/10 with diagnoses including dysphagia, nausea and vomiting, heart disease, kidney failure, etc. patient #17's care plan, created on 8/10/10. The care plan addressed the patient's risk for falls, activity intolerance. Patient #17's admission orders include "Restrain: yes as needed- chest (restraint) for patient safety". The CAH failed to include the use of the restraint in patient #17's care plan.

The CAH failed to create care plans for all patients and failed to assure the care plans are current for all patients.

Staff B and F, interviewed on 10/5/10 at 10:20am, confirmed the CAH failed to review and/or update the patient's plan of care as needed. The deficient practice affected patient's #2, 3, 10, 11, 12, 13, 15, 16,18, 19 and 20.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to assure providers timed, dated, and authenticated entries into the medical record for 19 of 20 records reviewed requiring physician signature as directed in the medical staff rules and regulations (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19 and 20).

Findings included:

- Patient record #1, reviewed 10/4/10 through 10/7/10 revealed an admission date of 8/10/10 and discharge date of 8/23/10. The patient record lacked provider's signatures, the date signed and/or the time the provider signed the document including therapy notes, radiology reports anesthesia records, dietitian recommendations and physician orders.

- Patient record #16, reviewed 10/4/10 through 10/7/10, revealed an admission date of 9/23/10 and discharge date of 10/7/10. The patient record lacked provider's signatures, the date and/or the time the provider signed the document including therapy notes, radiology reports, anesthesia records, dietitian recommendations and physician orders.


- Patient record #20, reviewed 10/4/10 through 10/7/10, revealed an admission date of 9/15/10 and remained a patient. The patient record lacked provider's signatures, the date and/or the time the provider signed the document including therapy notes, radiology reports, anesthesia records, dietitian recommendations and physician orders.

- Review of the Medical Staff Rules and Regulations revealed "The Patient's Medical Record" directs providers "All entries must be authenticated, time and dated". Interview with staff C on 10/4/10 to 10/6/10 confirmed the CAH failed to enforce the CAH's policies and procedures to date and time all entries in the clinical record.

The deficient practice also affected patient's #'s 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 17, 18 and 19.