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Based on interview and document review the facility failed to ensure the daily monitoring of emergency medications stored in the crash cart located in the surgery department. This had the potential to affect all surgical patients while in the surgical department.

Findings include:

During review of the documentation on the emergency crash cart logs located in the surgery department, it was noted the breakaway security locks (seals) had not been monitored for tamper evidence on a daily basis per facility policy. Logs were reviewed for the past 6 months and noted the breakaway locks had been monitored and checked for patency only 42 days out of 180 days during the 6 month period.

Review of the facility policy and procedure dated 9/14 for the emergency crash carts included: the charge registered nurse (RN) will monitor and document the last 4 digits of the breakaway lock daily followed by a signature for security of the medications.

Interview with the director of perioperative on 8/17/15, at 1:00 p.m. confirmed the emergency crash cart lacked monitoring to ensure it had not been accessed/tampered and indicated the breakaway locks should be checked daily.

Based on observation, interview and document review the Critical Access Hospital failed to ensure the integrity of sterile emergency supplies stored on 1 of 1 airway cart located in the emergency department (ED) and the respiratory therapy room so that supplies were readily available for treating emergency cases and failed to monitor the working condition of the defibrillator located on the emergency crash cart located in the Surgery department. This has the potential to affect any patient who required emergency and/or respiratory services.

Findings include:

On 8/18/15, during the ED tour from 3 p.m. until 4 p.m. the airway cart in ED rooms #1 was observed to have the sterile package integrity damaged by a hole being punctured into the sterile packaging:

ED room #1 airway cart:
-One endotracheal tube (ET) 6.5 millimeter (mm) (catheter inserted into the trachea to establish and maintain a patent airway) - label indicated the product sterility needs to be intact to ensure sterility, a hole was punctured into the packaging.
-One ET 4.0 mm - label indicated the product sterility needs to be intact, a hole was punctured into the packaging.

On 8/18/15, at 3:30 p.m. the ED registered nurse manager (RN)-A verified the damage to the integrity of the sterile packages and confirmed they should be discarded. The RN-A stated the ED did have a process to ensure the sterility of supplies on the supply carts and further stated the night shift staff check for outdates and should have removed the damaged packages. RN-A confirmed the chances of using the airway supplies in the ED rooms were high.

During a tour on 8/19/15, at 4 p.m. of the respiratory therapy (RT) department work room, the following outdated sterile supplies were observed:
-Four ET's 6 mm (catheter inserted into the trachea to establish and maintain a patent airway) - label indicated the product sterility is ensured until the expiration date listed on the package. All four ET were labeled "expired 3/2015".
-One king ET tube, size 4 mm labeled "expired 6/2014".
-One king ET tube, size 5 mm labeled "expired 6/2015".
-One meconium aspiration tube package labeled "expired 3/2015".
-five bags of inhalation humidification fluid, 1000 cubic centimeters (cc) label "expired 6/2015".

On 8/19/15, at 4:20 p.m. the RT manager (RT)-A verified the outdated medical supplies and confirmed they need to be discarded. The RT-A stated the RT department did have a process to ensure outdated items are removed before use by the evening shift staff person. RT-A confirmed the chances of using the airway supplies in the facility was high.

A policy related to monitoring for outdated "expired" sterile supplies was requested, but was not provided. A policy entitled "Ordering Emergency Items" was provided which did not address outdated supplies.

Review of the monitoring logs for the emergency crash cart located in the surgery department revealed the defibrillator had not been monitored on a weekly basis per facility policy. Logs were reviewed for the past 6 months and documentation indicated the defibrillator was monitored and checked only 4 times during the 6 month period.

Interview with the director of perioperative on 8/17/15, at 1:00 p.m. confirmed the emergency crash cart lacked the required monitoring and that it should be checked daily for cart supplies along with weekly defibrillator checks.

Review of the facility policy and procedure dated 9/14 for the emergency crash carts included: the charge registered nurse (RN) will perform weekly monitor checks per procedure, document and sign; the charge RN will check the top of the cart for supplies that included the defibrillator for proper working condition as well as checking availability of emergency supplies on a daily basis.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the emergency crash cart which contained medications were kept in a secure environment for 1 of 5 crash carts observed.

Findings include:

On 8/17/15, at 12:20 p.m. during a tour of the inpatient wing of the CAH, an emergency crash cart was observed in an alcove of a walk through area (which connected one hall to another). The cart was not in visible sight of the nursing staff and registered nurse (RN)-A confirmed the cart was not within view; therefore patients, visitors and non-nursing staff had access to the emergency crash cart. The emergency crash cart held a list of medications which were kept inside and plastic double locks were in place on the front of the cart. The breakaway locks/seals were easily broken by pulling on them, which was confirmed by RN-A during the tour.

A copy of the listed items located on and in the crash cart was provided by RN-B which revealed the cart contained numerous instruments including; syringes, scopes, needles and injectable medications such as Morphine Sulfate (an opioid analgesic), epinephrine (a stimulant) and 17 other injectable medications all potentially accessible to patients, visitors and non-nursing staff.

On 8/17/15, at 9:25 a.m. RN-A confirmed the emergency crash cart was designated for the medical/surgical unit and was not in sight of nursing staff.

On 8/20/15, at 10:12 a.m. RN-A confirmed the emergency crash cart was not secure and anyone could access it's contents which held controlled substances such as Morphine Sulfate and the potential for diversion and theft was evident due to the location of the car.

Review of the facility policy and procedure dated 9/14 for the emergency crash carts included: the charge registered nurse (RN) will perform weekly monitor checks per procedure, document and sign; the charge RN will check the top of the cart for supplies that included the defibrillator for proper working condition as well as checking availability of emergency supplies on a daily basis.

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 staff of the CAH.

Findings include:

During review of the CAH's emergency policies it was noted there was no agreement for potable/non-potable water in case of a emergency.

When interviewed on 8/18/15, at 2:00 p.m. the director of maintenance confirmed there was no current agreement or plan specifying the amounts of water required by various CAH departments in the event of a emergency loss of water, for both potable and non-potable water needs.

Interview on 8/18/15 at 3:00 p.m. the administrator verified the CAH lacked a written plan /policy for specific amounts of water (potable/non-potable) that would be required for use during an emergency situation.

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K50 and K29.

Based on interview and document review the critical access hospital (CAH) failed to develop ongoing hospital wide Quality Assurance Performance Improvement program (QAPI) monitors that included: organ procurement, clinical records, environmental services, and dietary services. This had the potential to affect all patients at the CAH.

Findings include:

When interviewed on 8/19/15, at 11 a.m. Health Information Services (HIS)-A staff, the clinic administrator (CA)-A and the quality staff (QS)-A were present. HIS-A indicated the heath information department collected and compiled the quality data which was stored in their department. HIS-A stated the compiled data is shared at the directors meeting, the medical staff meeting and the board of directors meetings. HIS-A confirmed he attends the medical staff meetings and the Quality Improvement Performance Improvement (QAPI) meetings. HIS-A stated that sometimes the departments implement the PDCA (plan, do, check, act) methodology but he does not monitor frequency of their reports nor does he follow up to be sure all departments have done their quality monitoring. QS-A said she submits the data required by regulatory agencies, but does not attend the medical staff nor board meetings. HIS-A, CA-A and QS-A all agreed no one person is in charge of QAPI at the facility and no one monitors the timeliness of each department's quality data, the analysis the data nor the annual effectiveness of their quality programs.


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On 8/19/15, at 3:40 p.m. the director of HIS-A stated there was no Quality Assurance Performance Improvement (QAPI) program related to clinical records. The HIS director further confirmed that no one monitors the timeliness of department's quality data, the analysis of the data nor the effectiveness of their quality programs on an annual basis.

On 8/19/15, at 9:00 a.m. registered nurse (RN)-A confirmed OPO services were not integrated into any QAPI program other than data collection by the procurement agency.


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Interview with the director of maintenance on 8/18/15 at 10:00 a.m. indicated the maintenance department did not have an on-going quality assurance program that monitors, collects quality data, analysis of the data or the effectiveness of the data. The maintenance director indicated if there was a problem in the department he would just fix it, but was not familiar with a quality improvement program.

Interview with the facility dietician on 8/18/15 at 10:30 a.m. indicated the dietary department did not have an on-going quality assurance program that collects quality data, analysis of the data or the effectiveness of the data. The dietician indicated a program may be beneficial to the department.

An interview on 8/20/15 at 11:05 a.m. with the administrator indicated that HIS-A was currently in charge of quality. The administrator indicated the facility reviews quality data annually and revealed the department manager is responsible to evaluate and monitor their own quality data.

Based on interview and document review the Critical Access Hospital (CAH) failed to analyze, evaluate the findings and consider appropriate actions to address the concerns identified from the data collected from nursing services, infection control, radiology, clinic services, radiology, cardiac rehabilitation, pharmacy, speech, laboratory, respiratory therapy, sleep studies, physical therapy, ambulance, occupational therapy, speech therapy and infusion therapy. This had the potential to affect all CAH and clinic patients

Findings include:
When interviewed on 8/19/15, at 1:23 p.m. registered nurse (RN)-A stated they have data collected on nursing service projects for QAPI; however, the data was not analyzed and there was no formal monitoring of the projects. RN-A confirmed there was no overall evaluation of the QAPI program related to nursing services.

On 8/17/15, at 1:45 p.m. the Infection Control Officer (ICO) stated the infection control committee usually met once a month. Quality Staff (QS)-A stated the committee collected data; however, the data was not analyzed and no action plan for improvement had been developed from the data collected to make corrective action.

A facility policy titled, Infection Control Committee, revised 11/2014, directed the committee to complete data collection, surveillance, analysis, and implementing a plan for program assurance.

On 8/19/15, at 11:00 a.m. clinic administrator (CA)-A stated she is in charge of all three clinic sites and they implement the Plan, Do, Check and Act (PDCA) methodology and agreed that no one is responsible to monitor the data collected and/or analyze the data to determine the effectiveness of their quality program on an annual basis.

When interviewed on 8/19/15, at 11:00 a.m. the director of Health Information Services (HIS)-A and QS-A both agreed no one person is in charge of QAPI so that analysis of the data collected is evaluated to determine the effectiveness of the quality program.

An interview on 8/20/15, at 11:05 a.m. with the administrator indicated that HIS-A was currently in charge of quality. The administrator indicated the facility reviews quality data annually and revealed the department manager is responsible to evaluate and monitor their own quality data.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure timely notification to the Organ Procurement Organization (OPO) for 3 of 5 patients (P1, P2 and P3) reviewed who expired at the facility.

Findings include:

P1 was admitted to the CAH on 8/2/15, at 5:01 p.m. P1 expired at the CAH on 8/3/15, at 12:50 p.m. The Organ Procurement Organization (OPO) was not notified until 2 hours and 28 minutes after death.

A facility policy titled, Tissue and Eye Donations (cardiac death) revised 6/2006, directed nursing services to contact the OPO as soon as possible. The policy lacked a definition of imminent death.

On 8/19/15, at 9:00 a.m. registered nurse (RN)-A stated the OPO should have been notified of P1's death within 60 minutes of death. RN-A confirmed the facility policy lacked a definition of imminent death, only cardiac death.

P2 had been admitted to the CAH on 5/6/15, at 7:45 p.m. unresponsive and in cardiac arrest and died. No documentation of when the OPO was notified of the death.

P3 had been admitted to the CAH on 4/10/15, at 7:56 p.m. after a motor vehicle accident in cardiac arrest and died. No documentation of when the OPO was notified of the death.

When interviewed on 8/19/15, at 9:00 a.m. RN-A confirmed there was no documentation of OPO notification time.

In addition the Critical Access Hospital (CAH) failed to define imminent death and integrate the definition in the CAH's policy and procedure.