HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of six, three skilled swing bed patients, one acute inpatient and two Emergency Department (ED) patients. Based on observation, interview and policy review, the CAH failed to provide for the safety of patients in one of two ED patient care rooms (ED trauma #1) when keys (which unlocked the cabinet above the drawers containing Hydrogen Peroxide and Isopropyl Alcohol) were found in a unlocked drawer and accessible to anyone in the room, the Pediatric Emergency Crash Cart and the Adult Emergency Crash Cart containing lifesaving medications were found unlocked and the CAH failed to secure potentially hazardous solutions in the dirty utility room on the inpatient floor. This deficient practice has the potential to cause harm to patients and visitors.

Findings Include:

- Emergency Department trauma room #1 observed on 7/25/2016 at 12:50 PM revealed the CAH failed to secure keys accessible to the locked cabinet containing one bottle of Hydrogen Peroxide and one bottle of Isopropyl Alcohol.

- Emergency Department trauma room # 1 observed on 7/25/2016 at 12:50 PM revealed the CAH failed to ensure the Pediatric Crash Cart was locked that contained four boxes of Sodium Bicarbonate syringes 10ml 4.2% ( a salt which is used in the bloodstream to regulate the body's acid-base balance).

- Emergency Department trauma room #1 observed on 7/25/2016 at 12:50 PM revealed the Adult Emergency Crash Cart unlocked that contained lifesaving medications.

Chief Executive Officer Staff A interviewed on 7/25/2016 at 1:00 PM acknowledged the keys in the drawer accessible to the locked cabinet should have been placed in their Pyxis (electronic dispensing of patient's medications). Staff A stated the Pediatric Crash Cart and Adult Emergency Crash cart should have been locked. Staff A immediately took the keys and placed them in the Pyxis.

- Policy titled "Emergency Department Cabinet" reviewed on 7/25/2016 at 3:00 PM directed the CAH "...the cabinets and crash carts in the Emergency Department will remain locked at all times. Keys to the locked cabinets and crash cart will be kept in the Pyxis system, which is accessible by nursing staff ..."


- Observation on 7/25/16 at 11:00 AM revealed both doors to the clean and dirty utility rooms were unlocked. The upper cabinets had locks on them but they were all unlocked. The solution Quat (an industrial disinfectant) unsecured and accessible to patients and visitors.

Interview on 7/25/16 at 11:10 AM with Staff B verified the doors were unlocked. She stated they are usually always locked.

Interview on 7/25/16 at 11:30 AM with Staff A, verified the doors were unlocked. They removed the accessible items and locked them in the housekeeping closet until more locks can be applied.

- Policy and Procedure reviewed on 7/25/16 at 3:00 PM was revised with an effective date of 7/27/16. Policy states: ...All potentially harmful substances, such as cleaning solutions, nail polish remover, shampoo and hemoccult solution will be stored in a locked cabinet in the cleaning in the clean and dirty utility rooms so they are not accessible to patients and visitors. The keys will be kept at the nurse ' s station ....

The Critical Access Hospital (CAH) reported a census of six, three skilled swing bed patients, one acute inpatient and two Emergency Department patients. Based on observation, staff interview, and policy review the hospital failed to ensure pharmacy services provided oversight in accordance with accepted regulations for repackaging of medications for one of two pharmacy medication rooms (Pharmacy stock room). This deficient practice has the potential to place all patients at risk for medication errors.

Findings include:

- Pharmacy stock room observed on 7/25/2016 at 10:45 AM revealed the following medications in Ziploc bags, labeled with medication name, dosage, and expiration date, lot number and manufacturer in four separate pharmacy general stock bins without the pharmacist signature:

1. L-Lysine 1000mg (an amino acid to build blocks of protein important for proper growth for bones, skin, tendons and cartilage) individual pills in a Ziploc bag with lot number, expiration date of 6/2018 and manufacturer Nature Bounty.

2. Lisinopril 10 mg (medication to lower blood pressure) individual pills in a Ziploc bag with lot number, expiration date of 5/2017 and manufacturer Mylan.

3. Zetia 10 mg (medication to lower cholesterol in blood) individual pills in a Ziploc bag with lot number, expiration date of 11/2018 and manufacturer Merck Company.

4. Cymbalta 20mg (medication to help with depression and nerve pain) individual pills in a Ziploc bag with lot number, expiration date of 3/2019 and manufacturer Breckenridge.

Chief Executive Officer Staff A interviewed on 7/25/2016 at 11:00 AM acknowledged the medications in the Ziploc bags did not have Staff F's signature. At 1:00 PM Staff A indicated Staff F came by the CAH and checked the medications in the Ziploc bags and verified the medications with their signature.

Pharmacist Staff F interviewed by phone on 7/25/2016 at 4:15 PM indicated they are going away with the Ziploc bags and to start a new pharmacy labeling system for all the medications that are repackaged. Staff F states they will do whatever the CAH needs them to do to correct the relabeling of medications.

- The CAH policy title "Pharmacist Oversight" reviewed on 7/25/2016 at 3:30 PM directed "...A new policy is put in place for repackaging any oral medication that does not come in individual sealed dosage packs...This log book contains the name of the medication, dosage, amount taken, area medication was dispensed to, signature of hospital Pharmacist repackaging the medication and date medication is repackaged ..." "...All repackaged medications will be placed in a resealable bag or medication bottle with label containing the name of medication, dosage expiration date, lot number and manufacturer of medication as exactly labeled on original medication bottle..."

Based on observation, interview and policy and procedure review the facility failed to ensure Staff D performed hand hygiene during 1 of 2 observations of staff performing tasks requiring hand hygiene. This failure has placed all patients at risk for infection.

Findings include:

- Observation on 7/26/16 at 9:40 AM revealed Staff D did not perform hand hygiene before and after applying Betadine (a topical antiseptic) to patient #11's surgical site. Hand hygiene was not performed before and after donning gloves throughout the procedure.

Interview on 7/26/16 at 11:10 AM Staff D verified the hand hygiene procedure and that they did not perform correct hand hygiene throughout the procedure.

- Policy and procedure review on 7/26/16 at 11:25 AM " Handwashing Policy " (effective date 5/26/16) states ...According to the Center for Disease Control and Prevention hand hygiene should be performed: ...Before and after direct contact with a patient ' s intact skin (taking a pulse or blood pressure, performing physical examination, lifting the patient in bed) ....After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings ...After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ...and before applying and after glove removal ...