HospitalInspections.org

Based on observation and staff interview the Critical Access Hospital (CAH) failed to secure medications in one of one medication cabinets used to store medications for Emergency Room (ER) patients to take home when they are unable to get prescriptions filled immediately.

Findings include:

- Observation in the medication room on 6/6/11 at 1:25pm revealed an unlocked medication cabinet used to store medications for take home medications for ER patients. The cabinet contained 56 different kinds of medications including, Acetaminophen 120 milligrams (mg) with Codeine 12mg solution (a narcotic pain reliever), Acetaminophen 300mg with Codeine 30mg, (a narcotic pain reliever)and Acetaminophen 500mg with Hydrocodeine 5mg (a narcotic pain reliever).

Staff B interviewed on 6/6/11 at 1:25pm acknowledged the unlocked medication cabinet and the missing lock on the cabinet door.

Staff C interviewed on 6/6/11 at 1:40pm revealed the lock broke on 6/4/11. Staff C acknowledged the unsecured medication cabinet.

Based on observation, staff interview and the lack of docuemnts for review, the Critical Access Hospital (CAH) failed to assure a process to clean the bedside computers in 21 of 21 patient rooms.

Findings include:

- Observation of the bedside computers mounted on a swing arm in patient room #14 on 6/8/11 at 10:30am revealed dust on the swing arm mount, computer monitor, keyboard and keyboard holder.

- Observation of the bedside computers mounted on a swing arm in patient room #116 on 6/8/11 at 10:30am revealed dust on the swing arm mount, computer monitor, keyboard and keyboard holder.

- Observation of the bedside computers mounted on a swing arm in patient room #18 on 6/8/11 at 10:30am revealed dust on the swing arm mount, computer monitor, keyboard and keyboard holder.

- Staff F, interviewed on 6/8/11 at 10:40am confirmed the presence of dust on the swing arm mount, computer monitor and keyboard. Staff F confirmed the cleaning of the computer unit is not included in the housekeeping cleaning tasks.

The CAH failed to identify the need to develop and implement policies and procedures for the cleaning of the bedside computer units.

- Observation of the physical therapy storage area on 6/7/11 at 10:40am revealed a drawer with eight syringes filled with fluid. Staff O, interviewed on 6/7/11 at 10:45am, confirmed the syringes contained a medication. Staff O confirmed the pre-filled syringes lacked a label identifying the contents, expiration date and who prepared the syringe.

- Pharmacy staff C, interviewed on 6/8/11 at 11:00am, confirmed pre-filled syringes require a label including the contents, expiration date and who prepared the syringe.














25604


Based on observation, staff interview, and document review the Critical Access Hospital (CAH) failed to ensure that unusable drugs and biologicals are not available for patient use in one of one contrast media warming cabinet observed. The CAH failed to properly label per-filled syringes according to professional standards in one of one medication storage drawer in the physical therapy room.

Findings include:

- The information sheet provided by the manufacturer of Visipaque (an intravenous dye) directed under storage "...may be stored in contrast media warmer for up to one month at 37 degrees Celsius (98.6 degrees Fahrenheit)..."

- The information sheet provided by the manufacturer of Optiray (an intravenous dye) directed under storage "...may be stored up to 40 degrees Celsius for up to one month in contrast media warmer..."

- Observation on 6/7/11 at 11:20am revealed a contrast media warming cabinet in the Cat Scan (CT) room contained ten 100mL vials of Optiray, two 50mL vials of Optiray, and one 100ml vial of Visipaque. The solutions lacked a date when placed in the warmer or when to be removed from use.

- Staff M interviewed on 6/7/11 at 11:20am acknowledged the Optiray and Visipaque lacked the date when placed in the warmer and were unaware of the temperature in the warming cabinet.

- Observation of the Emergency Room (ER) on 6/6/11 at 12:30pm revealed three open Yankauer suction tips ready for use in room #3. The package on the suction tips directed sterile unless opened or damaged.

Staff B interviewed on 6/6/11 at 12:30pm acknowledged the open Yankauer suction tips.






25604


Based on observation, staff interview, and document review the Critical Access Hospital's (CAH) infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for two of two observed glucometer checks, one of one observed cleaning of a discharged patient room, one of one observed cleaning of the endoscope room, and six of six observed open suction/endotracheal tubes ready for use.

Findings include:

- The CAH's policy for Infection Control Scope of Service reviewed on 6/8/11 at 9:20am directed "...The infection control program oversees all infection control activities ...provides for a safe environment of care for patients, visitors, and personnel...monitors and evaluates key performance aspects of infection control surveillance..."

- The manufacturer's guidelines for the "OneTouch" glucometer (a machine to test blood sugars) reviewed on 6/7/11/11 at 2:20pm directed "...All patient samples and materials with which they come in contact are considered biohazards and should be handled as if capable of transmitting infection ..."

- Staff L observed on 6/7/11 at 10:50am obtained a glucometer in a clear case from a drawer in the laboratory, entered patient #33's room, performed hand hygiene, and laid the cased glucometer on the bedside table without a protective barrier. Staff L applied gloves, removed the glucometer and supplies from the case and laid them on the bedside table without a protective barrier. Staff L obtained the blood sugar test, replaced the glucometer and supplies into the case, placed the case under their arm, removed their gloves, performed hand hygiene and left the room. Staff L entered patient #23's room, performed hand hygiene laid the cased glucometer on the patient's bed, applied gloves, removed the glucometer and supplies from the case and laid them on the bed without a protective barrier. Staff L obtained the blood sugar test, replaced the glucometer and supplies into the case, placed the case under their arm, removed their gloves, performed hand hygiene and left the room. Staff L returned to the laboratory and placed the glucometer case in a drawer. Staff L failed to clean the glucometer case, glucometer and supplies after each patients use.

Staff K interviewed on 6/7/11 at 12:20pm acknowledged the potential for cross contamination when staff failed to clean the glucometer after each patient use.

- The manufactures recommendation for "49" neutral germicidal cleaner reviewed on 6/8/11 at 11:30am directed for disinfection "...apply solution with a mop, cloth or hand-pump ...to wet all surfaces thoroughly ...Allow to remain wet for 10 minutes ..."

- The CAH's policy for hand hygiene reviewed on 6/8/11 at 9:20am directed " ...Whenever gloves are changed, hand hygiene should be practiced before donning a clean pair of gloves ..."

- Staff G on 6/7/11 between 1:05pm to 1:55pm cleaned room 14, a discharged patient room. Observations revealed the following breaches in infection control practices regarding hand hygiene and disinfectant wet time per manufacturer's recommendation. For example:

Staff G wearing gloves emptied the room of trash and returned to the cleaning cart in the hallway. Staff G removed their gloves and applied clean gloves. Staff G returned to the room wet a cleaning cloth with "49" disinfecting cleaner and cleaned the telephone and call light cord then removed a used oxygen set-up and placed the oxygen set-up in the trash container on the cleaning cart. Staff G removed their gloves and applied clean gloves. Staff G returned to the room and cleaned the bedside stand, bedside table, chair, and couch with "49" cleaner. The surfaces failed to remain wet for 10 minutes required for disinfection.

Staff G cleaned the room sink and counter with "44" cleaner. Staff G returned to the cleaning cart obtained "In The Pink" toilet bowl cleaner, went to the bathroom, squirted some in the toilet bowl and cleaned the bowl with a toilet mop. Staff G returned to the cleaning cart removed their gloves and applied clean gloves. Staff G sprayed the bathroom walls, toilet, sink and counter with "44" cleaner, then wiped the toilet seat and handles with "49" cleaner. The surfaces failed to remain wet for 10 minutes required for disinfection.

Staff G returned to the cleaning cart in the hallway removed their gloves and wet mopped the room with "44" cleaner.

Staff G failed to perform hand hygiene four times when they removed and reapplied gloves.

- Supervising staff H interviewed on 6/7/11 at 1:40pm acknowledged all surfaces failed to remain wet the required 10 minutes for disinfection. Staff H revealed "44" cleaner did not contain disinfecting properties.

- The manufactures information sheet for "44" cleaner reviewed on 6/8/11 at 2:45pm and "In The Pink" toilet bowl cleaner reviewed on 6/8/11 at 3:50pm revealed the cleaners failed to contain disinfecting properties.

- Supervising staff F interviewed on 6/8/11 at 3:50pm verified "44" cleaner and "In The Pink" toilet bowl cleaner failed to contain disinfecting prosperities.

- Administrative staff Q interviewed on 6/8/11 at 9:20am acknowledged the hospital's policy for hand washing required staff to perform hand hygiene before and after removing gloves.

- Staff I and staff J on 6/8/11 between 9:00am to 9:20am cleaned the endoscope room of the surgical suite. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation. For example:

Staff I and staff J using "49" germicidal cleaner cleaned a bedside stand, anesthesia cart, back up table, medication cart, scope tower, counter and a rolling cart. The surfaces failed to remain wet for the required 10 minutes for disinfection.

- Staff I and staff J interviewed on 6/8/11 at 9:20am acknowledged the surfaces failed to remain wet the required 10 minutes for disinfection.

- Observation in the recovery room of the surgical suite on 6/8/11 at 9:40am revealed two open yankhauer suction tips ready for use. The package on the suction tips directed sterile unless opened or damaged.

- Staff T interviewed on 6/8/11 at 9:40am acknowledged the open yankhauer suction tips.

- Observation in Operating Room #1 on 6/8/11 at 10:05 revealed one open yankhauer suction tip and one open endotrachael tube ready for use. The package on the suction tip and endotracheal tube directed sterile unless opened or damaged.

- Staff T interviewed on 6/8/11 at 10:05am acknowledged the open suction tip and endotracheal tube.

- Administrative staff Q interviewed on 6/8/11 at 3:30pm acknowledged they did safety and environmental rounds but failed to include surveillance for proper use of cleaning/disinfecting products.

Based on policy review, medical record review, and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 15 of 32 patient medical records reviewed (#'s 7, 11, 12, 13, 14, 16, 17, 20, 21, 22, 23, 24, 25, 28, and 30).

Findings include:

- The medical staff "Rules and Regulations" reviewed on 6/7/11 at 8:45am directed, "All entries must be authenticated, timed and dated."

- Patient #7's medical record reviewed on 6/7/11 revealed an admission to the Emergency Department (ED) on 6/9/10 with a complaint of elevated temperature and cough. Patient #7's medical record revealed the verbal orders lacked a date and/or time when authenticated (signed) by the provider.

- Patient #11's medical record reviewed on 6/6/11 revealed an admission date of 5/24/11 with diagnoses of Atrial Fibrillation (fast heart rate), Pleural Effusions (fluid in the lungs), and stats post a fall. Patient #11's medical record revealed between 5/24/11 and 6/6/11 seven written and/or cosigned verbal orders, and one progress note lacked a date and/or time when authenticated (signed) by the provider.

- Patient #13's medical record reviewed on 6/6/11 revealed an admission date of 5/27/11 with a diagnosis of stats post hip nailing. Patient #13's medical record revealed between 5/27/11 and 6/6/11 seven verbal orders lacked a date and/or time when authenticated (signed) by the provider.

This deficient practice also affected patient #'s 12, 14, 16, 17, 20, 21, 22, 23, 24, 25, 28, and 30.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to be informed of their total health status and medical condition in a language they understand (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to be informed of their total health status and medical condition in a language the patient understands.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the patient's rights information given to swing bed patients lacked the patient's right to be informed of their right to information in a language they understand.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to be informed in advance about care and treatment and changes in their care and treatment (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights informationwhich lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to be informed in advance about care and treatments and any changes in their care and treatment.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the CAH failed to inform swing bed patients of thier right to be informed about their care and treatment and any changes in care and treatment.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to be informed of their total health status and medical condition in a language they understand (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information. The clinical record lacked evidence the patient or their representative was invited to participate in planning care and treatment.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information. The clinical record lacked evidence the patient or their representative was invited to participate in planning care and treatment.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to participate in planning their care and treatment.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the CAH failed to inform swing bed patients of their right to participate in care planning and failed to include evidence the patient was included in care planning.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to work or refuse to perform work (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to work or refuse to perform work.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the patient's rights information given to swing bed patients lacked the patient's right to be informed of their right to work or refuse to perform work.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to receive and send mail (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to receive and send mail.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the patient's rights information given to swing bed patients lacked the patient's right to receive and send mail.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to visitors (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to visitors.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the CAH failed to inform swing bed patients of their right to visitors.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to retain and use personal possessions (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to retain and use personal possessions.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the CAH failed to inform swing bed patients of their right to retain and use personal possessions.

The deficient practice also affected patient #13.

The Critical Access Hospital (CAH) reported a census of 3 swing bed patients. Based on document review and staff interview, the CAH failed to inform their swing bed patients of their right to share a room with their spouse (patient #'s 11, 12 and 13).

Findings include:


- Patient #11's clinical record, reviewed on 6/6/11 at 1:00pm revealed a swing bed admission date of 5/24/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Patient #12's clinical record, reviewed on 6/6/11 at 1:45pm revealed a swing bed admission date of 5/27/11. The clinical record confirmed the patient was given patient rights information which lacked required rights information.

- Administrative staff A, interviewed on 6/6/11 at 3:55pm confirmed the document titled "Patient bill of Rights" is given to swing bed patients.

- The CAH's patient's rights document reviewed on 6/6/11 at 7:30pm revealed the CAH failed to inform swing bed patients' of their right to share a room with their spouse.

- Staff P, interviewed on 6/7/11 at 8:00am, confirmed the CAH failed to inform swing bed patients of their right to share a room with their spouse.

The deficient practice also affected patient #13.

Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to develop and implement an ongoing activity program and provide appropriate activities and interventions for each swing bed patient. The lack of evidence of an activity program affected 5 of 5 sampled swing bed patients (#11, 12, 13, 14 and 15).


Finding included:

- The CAH's policy titled "Patient Activities Guidelines", reviewed 6/8/11 at 2:30pm, revealed describes the activity program as a "planned, coordinated and structured manner".

- Patient #11's clinical record revealed a swing bed admit date of 5/27/11. The clinical record lacked evidence of an ongoing plan of activities, documentation of activities offered and the patient's participation in activities. Patient #11, interviewed on 6/6/11 at 12:30pm, revealed they did not recall activities being offered. The patient's room, observed on 6/6/11 at 12:30pm, lacked evidence of informing the patient of planned and structured activities. The patient's care plan lacked evidence of planned activity interventions.

- Patient #12's clinical record revealed a swing bed admit date of 5/27/11. The clinical record lacked evidence of an ongoing plan of activities, documentation of activities offered and the patient's participation in activities. Patient #12, interviewed on 6/6/11 at 1:15pm revealed they did not recall activities being offered. The patient's room, observed 6/6/11 at 1:15pm, lacked evidence of informing the patient of planned and structured activities. The patient's care plan lacked evidence of planned activity interventions.


- Staff E, interviewed on 6/7/11 at 3:00pm, confirmed the CAH failed to develop and implement an activity program with planned, structured activities for the swing bed patients.

The CAH's failure to develop and implement a "planned, coordinated and structured" activity program also affected swing bed patients #'s 13, 14 and 15.