HospitalInspections.org

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to assure to maintain cleanable surfaces in the laundry and kitchen.

Findings include:

- The CAH processes all their own laundry. The laundry area, observed on 4/12/11 at 11:20am revealed significant dust and other solid material near the washing machine. The floor near the washer revealed an unsealed, non-cleanable concrete surface. Staff A and M, present on tour, confirmed the presence of debris and the non-cleanable surface.


- The CAH's kitchen provides meals and snacks for the patients. The kitchen, observed on 4/13/11 at 8:30am, revealed chipped and peeling paint on the cupboards above the food preparations area. Staff N, present during the tour confirmed the non-cleanable surface.

The CAH failed to assure housekeeping staff and preventative maintenance programs kept the CAH free from debris and surfaces remain clean and cleanable.

Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals were not available for patient use in 1 storage cabinet in the operating (OR) room and 1 fluid warmer in the emergency room (ER), failed to ensure the safe storage and use of scheduled drugs, and failed to ensure only a pharmacist or registered nurse (RN) have access to the pharmacy.

Findings include:

- Review of the CAH's policy titled, "Requisition, Distribution, Outdate Monitoring and Processing of Pharmaceuticals" reviewed on 4/12/11 at 2:40pm directed staff to remove outdated medications and place them in the designated location labeled,"Expired; not for patient use".

- Observation on 4/12/11 at 8:30am of the cabinet in the OR revealed the following outdated drugs:
1. One-50 milliliter (ml) multi dose vial of Zylocaine (a drug used for local anesthesia) with an expiration date of 11/10.
2. Nine- 10 ml vials of Marcaine 0.75% (a drug used for local anesthesia) with an expiration date of 3/11/10.

Staff I interviewed on 4/12/11 at 8:30am acknowledged the outdated drugs in the cabinet in the OR.

- Review of the CAH's policy titled, "Environmental Monitoring and Control", reviewed on 4/12/11 at 2:40pm directed all fluids placed in the fluid warming cabinet are dated and discarded after 14 days.

- Observation on 4/11/11 at 1:45pm of the fluid warming cabinet in ER revealed the following fluids lacked a date when placed in the fluid warmer:
1. One-1000 ml bottle of sterile water for irrigation
2. One-250 ml bottle of 0.9% Sodium Chloride
3. Three-1000 ml intravenous bags of Lactated Ringers

Staff A interviewed on 4/11/11 at 1:45pm acknowledged the fluids in the fluid warming cabinet lacked a date when placed in the warming cabinet.

- Observation on 4/13/11 at 1:00pm of a single locked medication cart in the nurse's station revealed a drawer with a syringe of Demerol (a narcotic) 50 milligrams (mg) with half of the medication used. The drawer and/or syringe lacked a patient's name on it. Review of the narcotic sign out sheet revealed the Demerol was signed out to an outpatient. The narcotic sign out sheet lacked the amount of Demerol removed from the pharmacy and/or the amount of Demerol used and/or wasted.

Staff A interviewed on 4/13/11 at 1:00pm acknowledged the used Demerol syringe in the medication cart drawer and that staff failed to document the amount of Demerol removed from the pharmacy and failed to destroy and document the amount of unused medication.

- Review of the CAH's policy titled, "Access to Pharmacy and Pharmacy Keys", directed staff to the availability of three sets of keys locked in the controlled substance room and/or in the possession of the registered nurse only.

Staff A interviewed on 4/13/11 at 1:00pm acknowledged the Licensed Practical Nurses (LPN) carry a set of keys when working and access the pharmacy to retrieve medications.

Staff J interviewed on 4/14/11 at 11:00am acknowledged the LPN has access to the pharmacy to retrieve medication.

Staff L interviewed on 4/14/11 at 9:20am acknowledged the State Board of Pharmacy statute 65-1648 (a) only a designated RN can access the pharmacy.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) staff failed to conduct measures to prevent the potential spread of infection related to lack of proper hand hygiene and failure to follow the CAH's contact isolation policy.

Findings include:

- Patient #26's medical record, reviewed on 4/11/11 at 2:30pm revealed the patient was in contact isolation for an infection. Observation of the patient's room on 4/11/11 at 1:30pm revealed the CAH had supplies for contact isolation hanging on the room's door.

- Staff C, observed on 4/11/11 at 1:30pm, revealed staff C entering the patient #26's room wearing a cover gown, a mask and gloves. Staff C removed the soiled dressing. Staff C, after provider B obtained samples from the wound, removed the protective gloves and applied another pair of gloves without performing hand hygiene. Staff C applied the dressing in direct contact with the wound, removed the protective gloves, and applied another pair of gloves without performing hand hygiene.

The CAH's policy title "Infection control Plan- Hand Hygiene", reviewed on 4/12/11 at 2:30pm, revealed staff are to "decontaminate hands after removing gloves".

- Provider B, observed on 4/11/11 at approximately 1:35pm entered patient #26's room, wearing a gown, mask and protective gloves. A specimen was collected from the wound by provider B during the dressing change. After obtaining the specimen, provider B removed the protective gloves and exited the patient room while continuing to wear the cover gown

The CAH's policy titled "Standard Precautions" directs staff to "remove gown and perform hand hygiene before leaving the patient's environment".

- Staff I, observed on 4/11/11 at 2:00pm, revealed the staff member entering the room of a patient in contact isolation after obtaining a pair of gloves from the dispenser outside the room. A glove was dropped on the floor. Staff I picked up the glove from the floor, put the glove on and proceeded to begin to administer intravenous (IV) medication. The staff member was stopped by the surveyor just prior to accessing the medication and called away from the patient. When the surveyor asked if the glove had been on the floor the Staff I responded "yes", then returned to the patient and continued to work with the IV solution. Staff I then moved away from the patient, removed the contaminated glove, and put on another glove without performing hand hygiene. Staff I had the potential to administer IV medication to the patient while wearing a glove that had been dropped on the floor and failed to perform hand hygiene after removing the dirty glove.

The CAH failed to control the potential spread of infections.

Based on procedure manual review and staff interview the Critical Access Hospital (CAH) failed to ensure patient care policies and procedures were reviewed by a group of professional personnel on an annual basis for eight of eight policy and procedure manuals reviewed.

Findings include:

- Review of the policy and procedure manuals provided during the survey between 4/11/11 and 4/14/11 lacked evidence the manuals were reviewed annually by a group of professional personnel that included at least one doctor of medicine or osteopathy, at least one midlevel practitioner (Advanced Registered Nurse Practitioner or Physician Assistant), and at least one person not a member of the CAH staff.

Staff H interviewed on 4/11/11 at 11:30am acknowledged the CAH failed to perform an annual review of the patient care policy and procedure manuals by a group of professional personnel.

Staff A interviewed on 4/12/11 at 8:00am verified the patient care policies and procedure lacked an annual review by a group of professional personnel.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to assure providers sign, date and time all entries in the clinical records for 7 of 15 of admitted patients (patient #'s 18, 19, 20, 21, 27, 28 and 29).

Findings include:

- Patient #27's clinical record, reviewed on 4/13/11 at 8:30am revealed an admission date of 1/11/11 and date of death 1/14/11. The CAH failed to assure the provider dated and timed their authenticating signature on four verbal and/or telephone orders.

- Patient #28's clinical record, reviewed on 4/13/11 at 9:10am, revealed an admission date of 11/23/10 and discharge date of 12/1/10. The CAH failed to assure the provider dated and timed their authenticating signature on six verbal and/or telephone orders.

- Patient #29's clinical record reviewed on 4/13/11 at 10:00am revealed an admission date of 2/19/11 and discharge date of 2/21/11. The CAH failed to assure the provider dated and timed their authenticating signature on two verbal and/or telephone orders.

The deficient practice also affected patient #'s 18, 19, 20 and 21.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to protect approximately 400 envelops of x-ray films with patient's identifying information from loss, destruction or unauthorized use in an unlocked and unoccupied record storage area.

Findings include:

- The ultrasound room, near the physical therapy department and an entrance to the building, observed on 4/13/11 at 11:15am, revealed the door open to the room and no staff present. Random observations of the hallway during the survey revealed patients, staff and community members use the hallway. The shelves along the west wall held approximately 400 envelops of x-ray films with patient identifying information.

- Staff E, interviewed on 4/13/11 at 11:15am confirmed the presence of the unprotected records including patient information. Staff F, interviewed on 4/13/11 at 11:45am confirmed the CAH failed to secure the records.

- The CAH's policy titled "The purpose and Function of the Health Information management (HIM) Department" revealed "the storage of records shall be restricted to authorized personnel.".

The CAH failed to protect the records with patients' identifying information from loss, destruction or unauthorized use.

Based on the annual program evaluation documents and staff interview the Critical Access Hospital (CAH) failed to include the review of the health care policies as part of their annual program evaluation.

Findings include:

- Review of the annual program evaluation documents, reviewed on 4/13/11 at 3:40pm lacked evidence the health care policies were included in the annual program evaluation.

Staff H interviewed on 4/11/11 at 11:30am acknowledged the CAH failed to include a review of the health care policies in their annual program evaluation.

Based on policy review, medical record review, and staff interview the Critical Access Hospital failed to notify the Organ Procurement Organization (OPO) of all deaths that occur in the CAH for one of two death medical records reviewed (patient #1).

Findings include:

- Review of the CAH's policy titled, "Midwest Transplant Network Notification for Organ and Tissue Donation", reviewed on 4/13/11 at 4:00pm, directed staff to notify the OPO of all deaths.

- Patient #1's medical record reviewed on 4/12/11 revealed an admit date of 12/21/10 at 2:49pm to the emergency room with diagnoses of Acute Severe Respiratory Distress and Pulmonary Edema. Patient #1's medical record revealed the patient died on 12/21/10 at 3:32pm. The medical record lacked evidence the CAH notified the OPOof the patient's death.

Staff A interviewed on 4/13/11 at 8:30am acknowledged the CAH failed to notify the OPO of the patient's death.