HospitalInspections.org

Based on document and staff interview, the Critical Access Hospital (CAH) failed to ensure the periodic evaluation of its total CAH program included the number of patients served and the volume of services provided at the CAH for 6 of 6 Specialty Services provided (Allergy, Cardiology, Ears,Nose and Throat, General Surgery, Podiatry, and Rheumatology). Failure to include the number of patients served and the volume of services provided at the CAH could potentially result in the CAH failing to meet the needs of their patients. The CAH staff identified a current census of 4 inpatients at the beginning of the survey.

Findings include:

1. Review of the CAH policy "Critical Access Hospital (CAH) Periodic Evaluation," revised 3/2019, revealed in part, "... evaluation must include a review of: the utilization of services ... Number of Patients served and Volume of Services ..."

2. Review of the "Executive Summary, Critical Access Hospital Annual Report for Davis County Hospital" revealed the annual program evaluation lacked documentation of the number of patients served and the volume of services for the Specialty Clinics, Allergy, Cardiology, Ears, Nose and Throat, General Surgery, Podiatry and Rheumatology .

3. During an interview on 9/2/2020 at 3:30 PM, the Director of Quality verified the annual program evaluation lacked the number of patients served and the volume of services provided for the 6 Specialty Clinic Services provided by the CAH. The Director of Quality acknowledged the annual program evaluation lacked documentation of the number of patients served and the volume of services for Allergy, Cardiology, Ears, Nose and Throat, General Surgery, Podiatry, and Rheumatology.

Based on document and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 17 of 17 patient care services provided (Inpatient, Dietary, Emergency Department, Surgical Services, Labratory, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy, CardioPulmoary Services, Cardiology Services, and Specialty Clinic Services, Allergy, Cardiology, Ears, Nose and Throat, General Surgery, Podiatry and Rheumatology.) Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided at the CAH. The CAH staff identified a current census of 4 inpatients at the start of the survey.

Findings include:

1. Review of the CAH policy "Critical Access Hospital (CAH) Periodic Evaluation," revised 03/2019, revealed in part, "... evaluation must include a review of: ... active and closed clinical records ... for various criteria and quality indicators ... representative sample ... not less than 10% ..."

2. Review of the "Executive Summary, Critical Access Hospital Annual Report for the Davis County Hospital" revealed the annual program evaluation lacked documentation the CAH staff reviewed a sample of both active and closed clinical records for Inpatient, Dietary, Emergency Department, Surgical Services, Labratory, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy, CardioPulmoary Services, Cardiology Services, and Specialty Clinic Services, Allergy, Cardiology, Ears, Nose and Throat, General Surgery, Podiatry and Rheumatology.

3. During an interview on 9/2/2020 at 3:30 PM, the Director of Quality verified the annual program evaluation lacked documentation the CAH staff performed a review of a sample of both active and closed records for Inpatient, Dietary, Emergency Department, Surgical Services, Labratory, Radiology, Physical Therapy, Occupational Therapy, Speech Therapy, CardioPulmoary Services, Cardiology Services, and Specialty Clinic Services, Allergy, Cardiology, Ears, Nose and Throat, General Surgery, Podiatry and Rheumatology.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 affiliate physicians (Physician C) selected for review, received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review could potentially result in the CAH medical staff not knowing the physician potentially failed to provide adequate care to the CAH's patients, and potentially reappoint the physician to the medical staff when the information might have impacted the medical staff's decision. The CAH administrative staff identified Physician C provided care to 4 patients previous to his last reappointment and 6 patients in 2019.

Findings include:

1. Review of the CAH's network agreement, dated 7/1/16, revealed in part " ... Medical records review as part of the quality and medical necessity of medical care at the [CAH] ... shall be included in the services provided by [Network Hospital] ... Such review may be performed ... by examination of external peer review reports ...".

2. Review of the CAH's peer review services agreement, dated 2/20/15, revealed in part "... [Network Hospital] shall, upon the request of CAH, evaluate the diagnosis and treatment provided by physicians at CAH ...:.

3. Review of a CAH policy "Provider Peer Review," revised 6/2020, revealed in part "[CAH] shall maintain effective quality assurance through internal medical staff peer review and external peer review provided through an agreement with a network hospital ... [CAH] maintains an agreement with [Network Hospital] to objectively and systematically monitor and evaluate appropriateness of diagnosis and treatment, quality of patient care and clinical outcomes of medical care provided at [CAH] ..."

4. Review of external peer review for the selected physicians revealed the medical staff approved Physician C for reappointment to the Medical Staff on 11/13/18. The Board of Trustees approved Physician C for reappointment to the Medical Staff on 11/19/18. Physician C's file lacked the results of any external peer review conducted prior to Physician C's reappointment to the Medical Staff.

5. During an interview on 9/2/20 at 1:30 PM, the Director of Quality confirmed the CAH lacked documentation of external peer review for Physician C, prior to his last reappointment.

I. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure maintenance staff identified and developed a mechanism to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 1 of 1 patient Magnetic Resonance Imaging (MRI) (a common procedure to create detailed images of the organs and tissues within the body) bathroom, 1 of 1 Emergency Department (ED) bathroom, and 2 of 13 acute patient rooms tested. Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in skin burns. The CAH identified an average of 35 MRI's are performed per month, an average of 283 ED patients seen per month, and the acute care unit had an average daily census of 3 patients.

Findings include:

1. Observations revealed:

a. During tours of the MRI area, on 08/31/2020 at 4:21 PM and on 09/01/2020 at 7:30 AM, with the Plant Operations/Biomed Manager, revealed the water temperatures ranged between 122.3 to 113.5 degrees Fahrenheit in the MRI bathroom.

b. During a tour of the ED on 08/31/2020 at 4:20 PM, with the OR/Outpatient Services Manager, revealed the water temperature was 122.9 degrees Fahrenheit.

c. During a tour of the acute care unit, on 08/31/2020 at 10:05 AM with the Patient Services Manager, revealed the water temperatures ranged between 129.9 to 123.8 degrees Fahrenheit.



2. Review of policy "Preventive Maint of Water Dist & Plumbing System," effective 08/2020, revealed in part, "...Room inspections include plumbing. Water ... temperatures are recorded daily ..."

3. Review of the provided "acute Hot H2O Temp" log from January 2020-August 2020, measuring water temperatures from the hot water source revealed, water temperatures ranged from 97-140 degrees.

4. During an interview on 09/01/2020 at 8:30 AM, the Plant Operations/Biomed Manager revealed the maintenance staff only monitored water temperatures at the hot water boiler, and did not check the water temperature at the patient care faucets.






II. Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the surgery staff decontaminated the tubing from 1 of 1 Scope Buddy (endoscope flushing aid for flexible immersible endoscopes) after the completion of endoscopy procedures, in accordance with the manufacturer's directions. Failure to decontaminate the tubing from the Scope Buddy after the completion of endoscopy procedures could potentially result in bacteria growing in the tubing and potentially causing an infection in patients. The Operating Room/Outpatient Services Manager identified that the surgery staff performed an average of 295 endoscopy procedures from 07/01/2019 to 06/30/2020.

Findings include:

1. Observations during a tour of the surgery department on 09/01/2020 at approximately 1:15 PM in the Endoscopy Room in the Operating Room (OR) revealed use of a Scope Buddy during the endoscopy cleaning process and connected to the endoscopy equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract). Review of the manufacturer's instructions indicated in part, "End of Day Shutdown. Scope Buddy Decontamination Frequency: ... Overnight or weekend storage: leave full of decontamination fluid or clean water to maintain decontamination..."

2. During an interview at the time of the tour, Certified Surgical Technician (CST) B,Surgical Technician B, and the Operating Room/Outpatient Services Manager revealed the surgery staff did not decontaminate the Scope Buddy tubing at the completion of endoscopy procedures or at the end of the day.

3. During an interview at the time of the tour, the Operating Room/Outpatient Services Manager confirmed the manufacturer's directions for the Scope Buddy endoscopy flushing aid required the staff to decontaminate the tubing at the end of the day.



39445



III. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) Staff failed to follow the manufacturer's instructions for the Harmony Blood Glucose Monitoring System when they failed to label 2 of 2 newly opend bottles of glucose test strips with the opened date on the label. Failure to follow the Harmony Blood Glucose Monitoring System manufacturer's instructions for use may result in inaccurate blood glucose readings. The CAH reported the Emergency Department (ED) performed approximately 85 blood glucose checks in the past fiscal year.

Findings include:

1. Observation on 8/31/2020 during a tour of the Emergency Department, revealed a Harmony Blood Glucose Monitoring System in its case with an opened bottle of 50 Harmony Blood Glucose Test Strips, Lot # 16819114001. The bottle was not lableled with the date that the bottle, containing approximately 40 strips, was opened. House Supervisor D, provided a second opened, nearly full bottle of 50 Harmony Blood Glucose Test Strips, Lot # 16819124001, not labeled with the date it was opened.

2. Review of the Harmony Blood Glucose Monitoring System manufacturer's booklet, dated 2017, revealed in part, "Important: For vial test strips, record the "date opened" on the test strip bottle when you first open it. Six months after first opened, discard the bottle and any remaining test strips.... Do not use a test strip that has expired."

Review of the CAH policy "SOP Blood Glucose Monitor System", last approved 7/2020, revealed in part, " Test Strips are stable until the expiration date" The SOP (Standard Operating Procedure) failed to direct the staff to write the date on the label when the new bottle is opened and to discard the bottle and any remaining strips 6 months after the bottle was opened.

3. During an interview on 8/31/2020, while on tour of the Emergency Department, House Supervisor D verified the Harmony Blood Glucose Test Strips bottles had not been labeled when opened.

During an interview on 9/1/2020 at 2:13 PM Patient Services Manager reported the department just switched glucose monitors and blood glucose test strips a few months ago. The old brand blood glucose test strips were stable until expired. The new strips expired 6 months after opening. The Patient Services Manager reported she had not revised the SOP to reflect the required change in the procdeure.

Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the surgery staff changed 3 of 3 sterile water flush bottles after endoscopy procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The Operating Room/OutPatient Services Manager identified that the surgery staff performed an average of 295 endoscopy procedures from 07/01/2019 to 06/30/2020.

Findings include:

1. Observations during a tour of the surgery department on 09/01/2020 at approximately 1:15 PM in the Endoscopy Room in the Operating Room (OR) revealed 3 of 3 bottles B. Braun Medical 500 mL bottles of sterile water for irrigation connected to the endoscopy equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract). Review of the manufacturer's instructions indicated in part..."Sterile Water for irrigation USP is indicated for use as an irrigating fluid...discard unused portion of irrigating solution since it contains no preservative...single unit container..."

2. During an interview at the time of the tour, Certified Surgical Technician (CST) B, Surgical Technician B, and the Operating Room/OutPatient Services Manager indicated the surgery staff opened the bottles of sterile water for irrigation each day that endoscopy procedures are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscopy procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscopy procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

3. During an interview on 09/01/2020 at approximately 1:30 PM, the Operating Room/OutPatient Services Manager stated he reviewed and confirmed the manufacturer's directions for the B. Braun Medical 500mL of sterile water for irrigation. The Operating Room/OutPatient Services Manager acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient. The Operating Room/OutPatient Services Manager noted Hospira Sterile water is another source used for irrigation during endoscopy procedures. Documentation provided from the manufacturer revealed, "sterile water for irrigation...is intended for use only as a single dose."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure timely physician notification for the occurrence of a medication error for 3 of 7 medication errors reviewed. (Patient #1, Patient #2, and Patient #3). Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 4 patient on entrance, and an average daily census of 3 patients per day.

Findings include:

1. Review of "Reporting of Medication Errors, Adverse Drug Events and Drug Incompatibilites," last approved 08/2019, revealed in part: "...report must be made to the attending physician if a medication error...has harmed or has the potential to harm the patient...Documentation of the medication error...and consequent notification of the physician shall be recorded in the patient's medical record"

2. Review of " SOP Administration of Medication" last approved 07/2020, revealed in part: "All medication errors will be reported to the medical provider and house supervisor immediately...Include the date, time, and name of medical provider notified...Document the notification of the medical provider of the medication error in the electronic health record".

3. Review of medication errors from January 2019 to July 2020 revealed:

a. The nursing staff failed to perform a glucose test before administering insulin to Patient #1 on 08/22/2019 at 11:30 AM. Patient #1's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #1's medical care of the medication error.

b. The nursing staff administered wrong medications for two medications and wrong dose for one medication on 06/04/2020 at 07:50 AM. to Patient #2. Patient #2's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.

c. The nursing staff administered the wrong medication to Patient #3 on 02/25/2020 at 15:00 PM. Patient #3's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #3's medical care of the medication error.


4. During an interview on 09/01/2020 at 11:00 AM, the Chief Nursing Officer acknowledged the medication error paperwork for Patient #1, Patient #2, and Patient #3 lacked the required documentation that the nursing staff notified the patient's provider of the medication error.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that 1 of 1 infection preventionist/infection control professional responsible for the infection prevention and control program individual, had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership. Failure to comply with regulations could potentially hinder the infection prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing harm to patients and their safety.

Findings include:

1. Review of Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Medical Staff Meeting Minutes from August 2019 to July 2020 revealed that an appointment had not been made by the Medical Staff for the position of Infection Preventionist.

3. Review of the Governing Board Meeting Minutes from August 2019 to July 2020 revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

4. Interview with Infection Preventionist on 09/02/2020 at 10:30 AM confirmed that the Infection Preventionist had not been appointed by the Governing Board.

5. Interview with Chief Nursing Officer (CNO) on 09/02/2020 at 10:50 AM confirmed that new regulations had been received from CMS, however, the Infection Preventionist had not been appointed by the Governing Board.