HospitalInspections.org

Based on observation, policy reviews and staff interviews the hospital failed to post all required signage in the emergency department (ED). This deficient practice has the potential individuals entering the ED or waiting for treatment to be unaware of their rights

Findings include:

- Emergency Department observed on 4/17/2017 at 11:30 AM revealed one Emergency Medical Treatment and Labor Act (EMTALA) sign located inside the locked emergency department room with no other EMTALA signs posted at the emergency department entrance or the waiting room where all individuals entering the emergency department or waiting for services could see them.

Director of Nursing Staff A interviewed on 4/17/2017 at 12:00 PM acknowledged the entrance to the emergency department and the waiting room did not have the required EMTALA signs posted where they are likely to be seen by patients.

Policy review on 4/17/2017 at 1:00 PM revealed the hospital failed to provide a policy to ensure EMTALA signs are posted to ensure they are likely to be seen by patients entering the emergency department or in the waiting room.

In the case of a hospital as defined in §489.24 (b)—
(1) To post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency department (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor; and
(2) To post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX;

Based on observation, interview, and policy review, the Critical Access Hospital (CAH) failed to ensure food storage areas and food preparation areas were clean, expired food is removed from use, and failed to ensure outdated medical supplies are removed. This deficient practice has the potential to contaminate ice and food with chemicals and bacteria exposing all patients and employees to unsafe consumption of food items and ice and placed all patients in need of emergency medical services at risk for use of ineffective medical supplies leading to unsafe care.

Findings Include:

- Observation during facility tour on 4/17/2017 at 11:30 am in the food storage room next to the ice machine revealed three shelves filled with cleaning chemicals and a mop bucket with a dirty water in the bucket. Food products stored next to chemicals or dirty cleaning items can cause cross contamination of the food. Director of Nursing (DON) Staff A acknowledged the chemicals and mop bucket.

- Observation during facility tour on 4/17/2017 at 11:30 am in the food storage room was an ice machine with noticeable rust across the front of the ice machine directly below the opening into the ice bin. The presence of rust on the ice bin rendering the surface uncleanable and can lead to contamination when scooping ice out of the bin. DON Staff A acknowledged the rust.

- Observation during facility tour on 4/17/2017 at 11:30 am in the food storage room an exhaust fan covered in dust and dirt. DON staff A acknowledged the visible dirt on the exhaust fan.

- Observation during facility tour on 4/17/2017 at 11:30 am in the food storage room revealed the following outdated food items:
Waffle mix - 8 boxes: 4 boxes dated 11/16/2016, 3 boxes dates 12/14/2016, 1 box dated 6/21/2016
Mayonnaise - one jar dated 2/14/2017
Syrup - one container dated 4/19/2016, 6 boxes unlabeled
Raisins - 9 boxes dated 10/18/2016
Angel food cake mix -8 boxes dated 8/2016
Yellow cake mix -3 boxes dated 11/32/2016
Sapporo Japanese noodles -7 containers: 4 containers dated 3/22/2017, 3 containers dated 12/15/2016
Brownie mix -4 boxes dated 4/16/2016
Jell-O mix opened 7/8, 6/25
DON Staff A acknowledged the outdated food items.

- Observation of the kitchen on 4/18/2017 at 9:00am revealed all metal cabinets used for food and equipment storage had painted surfaces with chipped paint making the surfaces non washable.

Policy review on 4/18/2017 revealed the CAH failed to develop a policy for checking for food expiration regularly and proper storage of chemicals and contaminated items away from food storage areas.

Interview with Dietary Manager Staff D on 4/18/2017 confirmed the expiration dates are to be checked weekly when the deliveries are made and the products are to be rotated with the longest expiration date at the back of the shelf.

Interview with maintenance director Staff F on 4/18/2017 confirmed the rusted area of the ice bin, dirt on the exhaust fan, and chipped paint of the kitchen cabinets. Staff F stated the cabinets are in the budget to be replaced as soon as replacements are found.


- Observation of emergency room (ED) #1 at on 4/18/2017 at 9:00am revealed the following outdated supplies:
2 ETT (enotracheal tubes-inserted through the mouth or nose to secure an airway) size 8, found in ED crash cart expired 1/2017
7 tongue depressor found in ED crash cart, expired 11/2016
1 Sexual assault exam kit found in wall cabinet, expired in 2/2014
2 pap kits (trays with instruments for cervical exams) found in wall cabinet, expired 3/23/2017
1 inline burette, a sterile item, found with open packaging in top right cabinet
DON Staff A acknowledged all outdated supplies.

Policy review on 4/18/2017 revealed the CAH failed to develop a policy for checking supplies for outdates.

Based on document review and staff interview the facility failed to ensure 2 of 35 medical records were completed within 30 days (patients #21 and #23) and failed to ensure orders were signed by the provider for 1 or 35 medical records reviewed (patient #22). These deficient practices have the potential to cause incomplete patient information which could decrease the quality and accuracy of future health care.

Findings include:

- Patient #21's medical record reviewed on 4/18/2017 at 3:00 PM revealed the patient was admitted on 12/13/2016 and discharged 12/15/2016 with a diagnosis of chronic obstructive pulmonary disease (COPD, a group of medical conditions used to describe deteriorating lung function) and chest pain. The medical record revealed the discharge summary was signed on 1/17/2017, 33 days after discharge.

- Patient #23's medical record reviewed on 4/18/2017 at 3:45 PM revealed the patient was admitted on 11/30/2016 and discharged on 12/4/2016 with a diagnosis of right lower lobe pneumonia (infection of the lower right section of the lung). The medical record revealed the discharge summary was signed on 2/1/2017, 59 days after discharge.

- Patient #22's medical record reviewed on 4/18/2017 at 3:25 PM revealed the patient was admitted on 11/3/2016 and discharged on 11/6/2016 with a diagnosis of right upper lobe pneumonia (infection of the right upper section of the lung).The medical record revealed orders for an electrocardiogram (EKG, a test on the electrical functioning of the heart) on 11/3/2016 at 8:10 pm, and on 11/4/2016 6:30 am had not been signed by a provider.

Medical Records Staff T was interviewed on 4/19/2017 at 12:10 PM confirmed patient #21 and #23's discharge summaries were not signed within 30 days and patient #22's EKG orders were not signed. Staff T revealed they review all medical records for unsigned documents in the medical record and place notice in the provider's bin for completion. Staff T indicated there is no current process for holding providers accountable if documents in the medical record remained incomplete.

Policy titled "Medical Staff Bylaws" reviewed on 4/19/2017 at 11:00 AM directed " ...the attending physician shall be responsible for completion of the medical record of each patient ... and ... no record shall be considered complete until the appropriate signatures are obtained".

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to safeguard confidential patient information from possible destruction. This deficient practice has the potential to affect patients' records in two of two cardboard boxes located directly on the floor in the medical records room.

Findings include:

- The Medical Records room observed on 4/18/2017 at 1:15 PM revealed two Bankers boxes (cardboard boxes used to store medical records) placed directly on the floor.

Medical Records Staff T interviewed on 4/19/2017 at 1:15 PM acknowledged the boxes contained patients' medical records and sat directly on the floor and unprotected from damage from flood or pests.

Policies reviewed on 4/19/2017 at 1:20 PM revealed the CAH failed to develop a policy to ensure the protection of medical records from destruction.

Based on medical record review, consent form review, and interview, the Critical Access Hospital (CAH) failed to ensure documentation of advance directives in three of thirty-five records reviewed (patient #'s 11, 14, and 15). Failure to perform advance directive review with each patient admitted to the CAH puts all patients at risk of not being allowed to completely exercise their rights.

Findings include:

- Patient #11's closed medical record review on 4/17/2017 revealed an admission date of 3/4/2017 to swing bed with a diagnosis of weakness and discharged home on 3/16/2017. The medical record lacked evidence that advanced directives were reviewed with the patient.

- Patient #14's closed medical record review on 4/17/2017 revealed an admission date of 5/12/2016 to swing bed with a diagnosis of weakness and discharged home 6/13/2016. The medical record lacked evidence that advanced directives were reviewed with the patient.

- Patient #15's closed medical record review on 4/18/2017 revealed an admission date of 12/21/2016 with a diagnosis of weakness and discharged home on 12/39/2016. The medical record lacked evidence that advanced directives were reviewed with the patient.

"Treatment Authorization and Privacy Acknowledgment" consent form directs " ...19. Advance Directive Information: (complete for all patients including outpatients): Do you have a living will? Do you have a Medical Durable Power of Attorney (DPOA)? If yes, is the living will or DPOA on file? If no, were you given Advance Directive Education Material? ..."

Interview with medical records Staff Ton 4/18/2017 at 11:00 am confirmed that all patients admitted to swing bed or acute inpatient are to sign consents for treatment with every admission which includes options for advance directives.