HospitalInspections.org

Based on the certification survey completed on August 8, 2013, the facility was found not in compliance with Life Safety Code requirements at CFR ?485.623(d).

Refer to Life Safety Code deficiencies at regulations; K0027 and K0144 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

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 and/or disruption in supply this also includes the prioritizing the use of water until adequate supplies are available. This had the potential of affecting all patient, staff, visitors and services provided.

Findings include:

During the review of the CAH's policy titled Potable Water revised 12/2012; it identified the amount of water which was available from the City of Pipestone. It stipulated the National Guard could be contacted if there was an interruption of water service. It had not specified the amount of water needed terms of gallons of potable (used for drinking and cooking) and non-potable water per patient or staff need per day. It also lacked a specific contract with either the City of Pipestone or the National Guard.

In an interview with the Facility Service Manager on 8/7/13 at 10:45 a.m. he agreed the Potable Water policy lacked both a contract and a formula which would delineated the amount of water which would be required for both staff and patients in the event of a disruption of water service.

Based upon interview and record review, the hospital did not ensure a current roster listing each practitioner's specific surgical privileges were available in the surgical suite for 6 of 6 medical doctors (MD) with surgical privileges (MD-A, MD-B, MD-C, MD-D, and MD-E and MD-F) at the Critical Access Hospital (CAH).

Findings include:

During a tour of the surgical suite on 8/6/2013 at 9:30 a.m., the manager of surgical services verified that a current roster listing each practitioner's specific surgical privileges was not available in the surgical suite.

MD-A, MD-B, MD-C, MD-D, MD-E, and MD-F all had surgical privileges at the CAH.

The current Medical Staff by-laws, dated 9/24/2001, indicated a current roster of operating privileges of staff members shall be maintained and a copy of the roster should be posted in the office of the operating room supervisor.

The hospital policy in the Surgical Services department titled Roster of Surgeons' Surgical Privileges, dated 11/1/2010, indicated a roster of surgeons' surgical privileges shall be maintained at the main operating room desk and also in the scheduling area.

The Manager of the Surgical Suite was interviewed on 8/6/2013 at 10:00 a.m. and stated the roster of surgeon's surgical privileges which were available in the surgical suite had not been current.

Based upon interview and record review, the critical access hospital (CAH) did not ensure a comprehensive pre-anesthetic and post-anesthetic evaluation was completed by the certified registered nurse anesthetists (CRNA) for 9 of 10 patients ( P1, P2, P3, P4, P5, P6, P7, P8 and P10) who had a surgical procedure at the CAH.

Findings include:

Documentation of pre-anesthetic and post-anesthetic evaluations completed by the CRNAs had been incomplete and did not include all of the information described in the critical access hospital's anesthesia policies.

P1 had an inpatient surgical procedure under regional anesthesia administered by CRNA-A on 7/30/2013. Although the pre-anesthesia evaluation documented on the Anesthesia Record indicated either general anesthesia or regional anesthesia was planned, there was no indication the risks/ benefits/ alternatives had been discussed with the patient. There was no post-surgery-anesthesia note documented on the Anesthesia Record by CRNA-A. Registered Nurse (RN)-A, who worked in the surgical suite, was interviewed on 8/7/2013 at 11:15 a.m. and stated CRNA-A frequently dictated a post-anesthesia evaluation. However, the post-anesthesia evaluation was not located by medical records personnel.

P2 had an inpatient surgical procedure under general anesthesia administered by CRNA-B on 8/6/2013. Documentation of the pre-anesthesia evaluation on the Anesthesia Record was incomplete and did not include an evaluation of any patient or family history of anesthetic complications or an assessment of the patient's airway. Although the pre-anesthesia evaluation indicated the patient had a 50 year history of tobacco use, there was no documentation of an assessment of the patient's respiratory status. Documentation of the physical system assessment was incomplete. The post-anesthesia evaluation included a stamp which read "No apparent anesthetic complications. VSS [vital signs stable.]" There was no documentation of an assessment of the patient's cardiopulmonary status, level of consciousness, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P3 had an inpatient surgical procedure under general anesthesia administered by CRNA-B on 6/19/2013. Documentation of the pre-anesthetic evaluation on the Anesthesia Record was incomplete and did not include documentation of an assessment of any family history of anesthetic complications or an evaluation of the patient's airway. Documentation of the physical system abnormalities was incomplete. There was no documentation of a discussion with the patient of the risk, benefits or alternatives of the type of anesthesia which was planned. The post-anesthesia evaluation completed by CRNA B was a stamp which read "No apparent anesthetic complications. VSS." There was no documentation of an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P4 had a surgical procedure as an inpatient under monitored anesthesia care (MAC) administered by CRNA-A on 6/20/2013. The pre-anesthetic evaluation documented on the Anesthesia Record was incomplete and did not include an assessment of any family history of anesthetic complications, a list of current medications or identification of patient allergies. Documentation of an evaluation of the physical system abnormalities was incomplete. Although the anesthesia record indicated MAC was planned and general anesthesia would be used, if needed, there was no documentation of the discussion of the risk and benefits of the types of anesthesia methods with the patient. The post-anesthesia evaluation completed by CRNA-A did not include an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P5 had a surgical procedure as an inpatient under general anesthesia administered by CRNA-B on 7/6/2013. The pre-anesthetic evaluation documented on the Anesthesia Record was incomplete and did not include documentation of an evaluation of the patient's airway or an evaluation of the presence or absence of physical system abnormalities. The record indicated the patient used tobacco; however, there was no documentation of an evaluation of the patient's respiratory status. Although the anesthesia record indicated general anesthesia was planned, there was no documentation of the discussion of the risk and benefits of the anesthesia method with the patient. The post-anesthesia evaluation completed by CRNA-B was a stamp which read "No apparent anesthetic complications. VSS." There was no documentation of an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P6 had a surgical procedure as an inpatient under general anesthesia administered by CRNA-B on 7/11/2013. The pre-anesthetic evaluation documented on the Anesthesia Record was incomplete and did not include documentation of an evaluation of the patient's airway, assessment of patient or family history of anesthetic complications, a list of current medications or documentation of an evaluation of the presence or absence of any physical system abnormalities. Although the evaluation indicated a general anesthetic was planned, there was no documentation of the risks/ benefits/alternatives had been discussed with the patient. The post-anesthesia evaluation completed by CRNA-B was a stamp which read "No apparent anesthetic complications. VSS." There was no documentation of an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P7 had a surgical procedure as an inpatient under spinal anesthesia administered by CRNA-A. The pre-anesthetic evaluation documented on the Anesthesia Record was incomplete and did not include documentation of a discussion of the risks/ benefits/alternatives of the planned anesthetic. The post-anesthesia evaluation completed by CRNA-A did not include of an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.

P8 had a surgical procedure as an outpatient under regional anesthesia administered by CRNA-B. The pre-anesthetic evaluation documented on the Anesthesia Record was incomplete and did not include an evaluation of the patient's airway or an evaluation of all of the physical systems identified on the anesthesia record. The post-anesthesia evaluation completed by CRNA-B indicated that no anesthetic complications had been noted and vital signs were stable. There was no documentation of an assessment of the patient's level of consciousness, cardiopulmonary status, any follow-up care or observations needed related to anesthesia or any complications which had occurred during post-anesthesia recovery.


10155

P10 had a surgical procedure with anesthesia and a thorough post-anesthesia evaluation was not completed.

It was noted during the surgical record review that the post-anesthesia evaluation had not been complete for P10, who had an epidural anesthetic administered on 8/3/2013 for a surgical procedure. The anesthesia evaluation was a stamped note that read "No Apparent Anesthetic complications Noted. VSS." No other documentation was evident regarding the status of the patient post operatively.

Registered nurse RN-A, who worked in the surgical suite, reviewed the anesthesia records and confirmed these findings.

The hospital policy Anesthetic Risk and Evaluation, last revised 8/10/2007, was provided by the Manager of Surgical Services. The policy indicated the credentialed anesthesia provider would conduct a pre-anesthesia visit with the patient and complete the pre-anesthesia evaluation form. The assessment would include a history of any previous anesthetics, any anesthetic complications and a list of current medications and allergies to medications. An airway evaluation would be conducted and a review of physical system abnormalities would be included in the evaluation. Notations would include the planned anesthetic technique and any special monitoring requirements. A discussion of the risks/ benefits/ and alternatives to the planned anesthesia would occur with the patient.

A review of the Anesthesia Record indicated the pre-anesthesia evaluation included a physical system review which included areas to document relevant findings as well as documentation of findings which were within normal limits.

When interviewed by telephone on 8/12/2013 at 1:30 p.m., CRNA B stated he completed a pre-anesthesia evaluation according to the hospital policy but did not document all of the findings and did not document if the findings were within normal limits. He stated he documented by exception (this means they only document negative findings otherwise it is assumed that there was no problem/s.)

The Director of Health Information and Compliance was interviewed by telephone on 8/12/2013 at 2:15 p.m. She stated she was not aware the hospital had a policy which permitted documentation on the Anesthesia Record which did not include documentation of all relevant findings.