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Based on the certification survey completed on June 6, 2013, the facility was found not in compliance with Life Safety Code requirements at CFR ?485.623(d).

Refer to Life Safety Code deficiencies at regulations; K-0011, K-0017, K-0029, K-0033, K-0038, K-0050, K-0052, K-0054, K-0056 and K-0072 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on interview and document review the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency. This had the potential to affect all patients and services provided.

During review of the CAH's Emergency Water Supply policy FAC-0001, with the latest revision 6/12, it was noted there was a detailed plan of how much water, both potable and non potable would be needed in the event of disruption of water service. Although, this plan identified two proprietors who could possibly furnish water in the event of an emergency, there wasn't an agreement or contract which established a definite commitment. In an interview on 6/5/13 at 1:30 p.m. with the facility manager, he confirmed this finding.


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Based on observation and staff interview, the critial access hospital (CAH) failed to ensure proper sanitation measures were taken in the kitchen. This had the potential to affect 9 of 9 patients currently in the facility.

During the kitchen tour conducted on 6/4/13 at 8:38 a.m., it was observed the floor throughout the kitchen had an accumulation of food debris and dust under and between all of the cabinets, food preparation area and food service area. There were two electric cords suspended from the ceiling directly above the tray service area which had a build up of grease and dust. The certified dietary manager (CDM) stated during interview on 6/6/13 at 9:15 a.m., that the vents above the steamer and cooking range had not been cleaned in approximately one year. There was an area on the floor behind the stove and food steamer which was covered with a heavy residual of a brownish substance. In addition, 8 of 9 nine inch frying pans were observed to be peeling and were missing the non-stick coating, and 2 of 3 spatulas which were observed to be gouged and had sections of the edges missing.

In an interview with the CDM on 6/6/13 at 10:15 a.m., she agreed with these findings and was going to encourage the staff in the kitchen to be more diligent with the cleaning of the kitchen.

Based on observation, interview, and documentation review, the Critical Access Hospital (CAH) was out of compliance with the Conditions of Participation for Surgical Services (CFR 482.51). The cautery instrument used to cut and cauterize tissue during surgical procedure was not holstered between uses and alcohol based skin preparation was not allowed to dry before draping. The practices increased the risk of patient burn and/or surgical fire for 1 of 2 patients (P12) observed in surgery.

Findings include:

The CAH did not implement policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in inpatient anesthetizing locations in CAHs. The use of an alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to preventing surgery related fires.


P12 was observed during a surgical excision of a large mass just below the hairline at the back of the neck on 6/4/13. At 10:17 a.m., the circulating registered nurse (RN)-D started the skin prep by shaving a small amount of hair and applying the alcohol based surgical skin prep to P12's neck just below the hairline. At 10:19 a.m., immediately following application of the skin prep, the surgical technician (ST)-A arranged the cloth drapes around the neck area. The larger drapes were then applied to cover most of P12's head. The package information indicated the skin prep contained 62% Ethanol (alcohol) with a warning, "WARNING: FLAMMABLE, KEEP AWAY FROM FIRE OR FLAME." The insert also indicated the solution contained alcohol with flammable vapors and the patient should not be draped until the solution was completely dry. The insert indicated that dry time would take a minimum of 3 minutes on hairless skin and up to an hour in hair. The insert indicated to avoid getting solution in hairy areas.

RN-D, interviewed on 6/4/13, at 10:20 a.m., stated that she doesn't have to let the skin prep dry because it doesn't have alcohol in it. She stated that it was a "one step prep." RN-D stated that they have been using this one step prep since August of last year (2012). ST-A stated that you didn't have to let the one step prep solution dry, referring to the skin prep they had just used. RN-D read the package insert with the warning notice, but continued the procedure. RN-D did not know that Ethanol was alcohol.

P12's surgeon (S)-A was observed to use the cautery 17 times starting at 10:26 a.m. though 10:58 a.m.. S-A did not holster the electrosurgical pencil/blade when it was not in use. The CAH did not have a holster for the cautery pencil and the pencil was placed directly on the drape over P12's head each time it was not in use.

The single use cautery pencil was a Valleylab Rocker Switch Pencil model number E2515 and, according to the manufacturer's web site, was available with a holster.

On 6/4/13, at 10:45 a.m., RN-D was interviewed and stated the cautery pencil doesn't come with a holster. Interview with the certified registered nurse anesthetist (CRNA) at approximately 10:46 a.m. indicated that, under the drape, P12 was receiving 4 liters of oxygen through a nasal cannula. Interview with ST-A at 10:48 a.m. stated the holster was not used because it was not available in the CAH for use with the needle tip cautery.

The surgical manager (RN)-E, interviewed on 6/4/13, at 11:02 a.m., stated the one step skin prep they were using didn't have to dry as long as the two step. RN-E said that they did not have a policy or procedure to ensure alcohol based skin preparations were dry before the patient was draped for surgery. Regarding policies or procedures for safe use of the cautery instruments, RN-E said they wouldn't use a holster for the cautery for small cases. She further clarified that they did not stock any holsters. She said that when using larger instruments that could slide off tables they "self made" holsters with towel clips.

Interview with the chief operational officer (COO) and surgery manager on 6/4/13, at 1:30 p.m. indicated there had been no surgical fires in the CAH. They confirmed the lack of policies and procedures to address safe use of alcohol preps and cautery. The COO said that they have utilized a surgical fire safety video within the last year for training. The training program was reviewed and did not address the safe use of alcohol preps or cautery.

Based on interview and document review, the critical access hospital (CAH) failed to assure the certified registered nurse anesthetist (CRNA) evaluated, and documented a post-anesthesia evaluation for each surgical patient including: cardiopulmonary status, level of consciousness, complications during the procedure and recovery, and follow up care and/or observations, required for 2 of 4 patients (P17, P16) whose surgical records were reviewed.

Findings include:

P17 was admitted on 12/14/12, and went to surgery on 12/20/12, for a laparoscopy inguinal hernia repair with intravenous (IV) sedation. P17 had an episode of lost pulse and blood pressure requiring cardiac compressions at the end of the surgery. The CRNA's postanesthesia discharge note dated 12/20/12 (no time documented), indicated R17's vital signs were stable. The post anesthesia evaluation was signed by the CRNA, but did not include P17's level of consciousness or follow up care required following the cardiac event.

P16 had surgery on 05/22/13, for right knee irrigation with IV sedation. The post anesthesia evaluation note indicated P16 was breathing with ease and the vital signs were stable. The postanesthesia note did not include the level of consciousness.

The registered nurse surgical manager (RN)-E, interviewed on 06/5/13, at approximately 11:30 a.m., stated she was not sure what the policy directed to be included in the post anesthesia note.

The facility's Safe Use of Anesthesia policy, dated as last reviewed on 10/12, indicated a post anesthesia note would be made when the patient was turned over to the PACU nurse. The note was to include vital signs, oxygen used, note of report given to PACU nurse, adequacy of ventilation and other pertinent observations. In addition, the policy indicated another note would be made after the patient had recovered from the anesthetic, and that one of the notes should state whether or not there had been any problems. It noted the entry should be documented 3-24 hours post-op (post operative) noting the presence or absence of anesthesia complications.

On 6/10/13, after exit, the CAH sent a FAX with a second policy and procedure titled, PACU, Discharge of Patient dated as reviewed on 12/12. The policy indicated anesthesia staff would review the "risk score" which was completed by the PACU nurse. The policy did not direct the CRNA to assess the patient and document the results of that assessment.

On 6/14/13 at 11:30 a.m. the CRNA was interviewed by phone and stated the Postanesthesia Note on the anesthesia record was what he considered his last assessment of the patient before discharge from anesthesia. The CRNA stated that he remembered P17's case and should have noted the level of consciousness, follow up care and any further observations that were needed.