HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of two swing bed patients, and five acute inpatients. Based on observation, staff interview and policy review the Critical Access Hospital failed to ensure the Surgery Unit Malignant Hyperthermia cart was locked and secured for one of one Malignant Hyperthermia cart and failed to ensure the Surgery Unit Eye room medications were locked and secured for one of one Eye rooms. This deficient practice has the potential to cause harm to patients, staff and visitors. Drugs and biologicals must be stored in a secure manner to prevent unmonitored access by unauthorized individuals. Drugs and biologicals must not be stored in areas that are readily accessible to unauthorized persons.

Findings Include:

- Observation of the surgical unit on 8/28/2017 at 12:57 PM revealed the equipment room unlocked. The equipment room contained the Malignant Hyperthermia cart which was also not locked. The main Operating Room doors were unlocked as well allowing unauthorized individuals accessible to the medications and supplies in the Malignant Hyperthermia cart.

Interview with Director of Nursing Staff A on 8/28/2017 at 12: 57 PM acknowledged the Malignant Hyperthermia cart, the equipment room door and the Main OR doors were unlocked. Staff A stated it is our policy to make sure that all emergency carts are locked and secured. The surgical unit was under minor repairs allowing maintenance workers to enter unit at any time. Staff A indicated that Staff B should have called pharmacy right away after opening the Malignant Hyperthermia cart at 11:55 AM to have them secure the cart.

Interview with Manager of Surgery Staff B on 8/28/2017 at 1:10 PM acknowledged they were going to call pharmacy and secure the Malignant Hyperthermia cart.

- Policy titled "Crash Carts" reviewed on 8/28/2017 directed staff " ...Check daily that lock is in place and secure, document lock number (last 3 numbers); to indicate integrity of medications/supplies ..."

- Observation of the surgical unit on 8/30/2017 at 1:00 PM in the Eye room revealed the following unsecured/unlocked medications in the cabinet:

1) 2 bottles of Tobradex (antibiotic-cure infection)

2) 2 vials of Lidocaine (numbing medication) 4% 200mg/5 milliliters

3) 6 Betadine (prevent infection) 5% sterile ophthalmic pre solution 1 ounce

4) 8 Miochol (medication to obtain rapid and complete constriction of the pupil) 0.2 micron intraocular solution 1:100

5) 15 sterile irrigating solution 15 milliliters

6) 12 Vision blue ophthalmic solution (gives a clear look to the eye during eye surgery)


Interview with Director of Nursing Staff A on 8/30/2017 at 1:00 PM acknowledged the medications in the Surgery Eye room were unsecured and unlocked in the cabinet.

- Policy titled "Pharmacy Inventory Management" reviewed on 8/30/2017 directed staff " ...All drugs shall be stored in secure areas in accordance with established standards for each individual drug to maintain the drug's integrity..."

The Critical Access Hospital (CAH) reported a census of two swing bed patients, and five acute inpatients. Based on observation, staff interview and policy review the Critical Access Hospital failed to ensure the expired food on the Medical Surgical Unit kitchenette was disposed for one of one kitchenette. This deficient practice has the potential to expose all patients to bacterial contamination and cross contamination resulting in foodborne illness.

Findings Include:

- Kitchenette on the Medical Surgical unit observed on 8/30/2017 at 10:45 AM revealed the following expired food in the refrigerator:

1) Five thick and easy (a drink with a thicker consisistency that makes it easier to swallow without aspirating into the lungs) apple juice containers with expiration date of 8/23/2017.

RN Staff G interviewed on 8/30/2017 at 10:45 AM acknowledged the juices were expired and should have been disposed.

- Policy titled "Food Storage" reviewed on 8/30/2017 directed staff " ...Nutritional supplements are checked for outdates weekly. Outdated items are disposed of and reordered as needed

The Critical Access Hospital (CAH) reported a census of five acute inpatient and two swing bed patients. Based on documentation review, staff interview and policy review the Critical Access Hospital failed to ensure their staff provided the patient's skin integrity needs for one of one patient (patient #1) reviewed at risk for skin breakdown. This deficient practice has the potential for the patient to acquire skin breakdown.

Findings Include:

- Documentation of medical record reviewed on 8/29/2017 revealed patient #1 was admitted as an inpatient on 4/9/2017 with a diagnosis of Urinary tract infection (UTI-bacterial infection in urinary tract). Patient's order for activity was bedrest with bathroom privileges. Patient's Braden skin assessment was 15 indicating the patient was "at risk" for skin impairment and preventative interventions such as a regular turning schedule, activity as possible, protecting the heels, use of a pressure redistribution surface (i.e. air mattress, foam mattress, etc.), managing moisture, friction, and shear, and increasing the patient to a higher level of risk if other major risk factors are present. Patient #1 had a Foley catheter upon admission and the catheter was last changed by home health recently. Patient #1 had chronic debilitating Multiple Sclerosis (disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged) and was wheelchair bound, obese, total care, had chronic weakness in lower legs and had been unable to bear weight for years. Patient's upper extremities have increasingly worsened over the past 2-3 weeks.

Patient's caregiver told RN Staff I there were no open areas on Patient #1's buttocks prior to coming to the CAH and they applied zinc oxide paste to the buttocks nightly. Record review lacked documentation that Patient #1 had skin breakdown on admission to the CAH on 4/9/2017. During a shower on 4/11/2017 (2 days after admission) patient #1 complained of pain in the buttocks area. RN Staff E noticed a purplish red area on the buttocks (not open at that time). Staff E explained to patient #1 they need to turn them every couple hours to prevent breakdown. Staff E noticed his right heel had become soft and heel protectors were placed bilaterally to his feet (2 days after admission).

Prior to patient's dismissal on 4/12/2017, Staff J and Staff K transferred patient #1 off the commode and Staff J noted a small opening at the upper part of buttocks. Staff J reported the opening to patient #1's nurse that day (Licensed Practical Nurse (LPN) Staff G.

Interview with RN Staff J on 8/30/2017 at 11:45 AM, remembered helping transfer patient #1 to the commode. RN Staff K did the wiping and Staff J held the patient and noticed some small amount of pink fluid on the tissue and saw a small crevice near the very top of the buttocks. We applied Mepilex Border barrier (all-in-one foam dressing use to prevent pressure ulcers and provide a healing environment for small wounds with little drainage) to protect the open slit.

Interview with LPN Staff G on 8/30/2017 at 10:50 AM, remembered on the day of discharge the patient needed to use the commode. So, RN Staff J and RN Staff K transferred the patient to the commode. Staff J reported to Staff G that the patient has a small crevice at the top of their buttock and Staff J applied a barrier.


The medical record lacked documentation that the nursing staff recognized that patient #1 should have advanced to a higher level of risk for skin breakdown due to his chronic illness. The medical record lacked documentation that patient #1 was turned/repositioned every 2 hours. The record showed that heel protectors were placed on the patient only after the nurse noticed one of patient #1's heels was soft (2 days after admission). The medical record lacked documentation of an order for a pressure - redistribution surface. The medical record lacked documentation that Staff E notified the physician on 4/11/2017 of the purplish red area on the buttocks. The medical record lacked documentation Staff G notified the physician on 4/12/2017 of the small open area to the buttocks or consulted the wound care nurse prior to the patient's discharge.

The discharge teaching documentation sheet instructed patient #1 and their caregiver "Reposition every 1-2 hours until area on buttocks heals. Notify PCP (Primary Care Provider) if area becomes open"; even though there was documentation of an open area on the buttocks prior to the patient's discharge.

Director of Nursing Staff A interviewed on 8/30/2017 at 1:30 PM. Staff A indicated the Wound Care Nurse only gets involved if a patient has an open wound otherwise nursing is responsible for patient's skin integrity. Staff A reviewed patient #1's chart and did not see an order for any specialty bed or orders for skin breakdown prevention measures. Also, Staff A did not see any documentation that Staff E notified the physician of the purplish area on the patient's buttocks on 4/11/2017 or that Staff G, who was caring for the patient on 4/12/2017 prior to patient #1's discharge, notified the physician of the opening on patient #1 buttocks or a consult for the wound care nurse.

- Policy titled "Pressure Ulcers and Skin Integrity with Algorithms and Protocols For Care" reviewed on 8/30/2017 directed staff " ...To identify patients at risk for pressure ulcer development and skin breakdown; to implement prevention; to provide care for pressure ulcers and skin breakdown ..." " ...to maintain an optimal level of skin integrity and to promote optimum healing of pressure ulcers and skin breakdown using an individualized plan of care ..." " ...Document wound and skin cares in chart ..."

The nursing staff failed to protect patient #1 from aquiring skin breakdown during his hospitalization at the CAH.