HospitalInspections.org

Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiency cited at: K0341, for additional information.

Based on interview and record review, the facility failed to follow their policy related to reporting to the State agency allegations of mistreatment for 1 of 1 patient (P2) with allegations of mistreatment.

Findings include:

Review of the medical record revealed P-2 was brought to the ER on 6/25/17 for a failed suicide attempt at gunpoint with police intervention. The ED (emergency department) Provider Note dated 6/25/17 indicated P2 had made comments such as "has nothing to live for" and he feels like a "burden" to his family and wishes some days he would go to sleep and not wake up. He denied planning the attempt and was deemed not acutely suicidal, but had not indicated that he would not have harmed himself had he been discharged and left the hospital. The ED Provider note indicated P2 had a diagnosis of suicidal ideation, and had been be admitted to the hospital with possible transfer for inpatient mental health treatment for his safety. The note indicated a mental health hold would be put in place if P2 attempted to leave the hospital.

A physician (MD) progress note dated 6/26/17, written by MD-B, indicated P-2's relationship with his son had become "Quite toxic, with [P2] the brunt of mental, emotional, financial abuse. Physical abuse possible as [P2] has had objects thrown at him. This is a significant change from [P-2] 2-3 years ago. His son arrived on the scene about 2 years ago and since then [P2] mood and activity have decreased. In visiting with [P2], his son has taken away his phone, does not allow him to go golfing- which is [P2's] favorite summertime activity, as is also acquired [P2's] social security check and finances so that [P2] really is left quite helpless without recourse." MD-B noted he had placed a call to the local county social services for help.

During interview on 6/27/17, at 1:50 p.m. with the licensed social worker (LSW)-E, she indicated her role was to assist with discharge planning for the facility. She would meet twice weekly with staff and discuss briefly any needs patients may have. The facility process was nursing staff were to have called her to alert her to any concerns related to social services. The discharge planner, registered nurse (RN)-C was responsible to report vulnerable adult concerns. Her understanding was the discharge planner called the county social services department and made a report.

During interview on 6/27/17, at 2:20 p.m. the director of nursing (DON) indicated she had not had a chance to review the complete details surrounding the events leading up to P2's admission found in the electronic medical record (EMR). In review of P-2's EMR, she agreed a report should have been filed immediately to the Minnesota Department of Health (MDH) and the facility's policy regarding vulnerable adult (VA) reporting should have been followed. The DON's expectation was staff were to have reported any vulnerable adult to herself or RN-C.

During interview on 6/28/17, at 11:45 a.m. RN-C indicated she had not reported per the facility policy as she felt the doctor had reported it to the county social services. She stated looking back, she should have reported it to MDH. She had only reported one vulnerable adult case once before, only after a patient's family had brought concerns to her attention. She agreed staff needed training at recognizing VA cases and reporting them to MDH appropriately.

During interview on 6/28/17 at 12:30 p.m. with RN-D she had worked at the facility as a nurse since 2005 and had never filled out a VA report. She was unaware of the appropriate VA reporting method indicated within the facility's policy. She indicated if she did had a VA case to report, she would notify either the DON or RN-C when available. She was unsure where to find information on how to report a VA and could only find information on the state ombudsman's office.

During interview on 6/28/17 at 1:20 p.m. with MD-B, who was also the medical director for the facility, revealed he was unaware the facility had not appropriately reported P2's case to MDH. He was not aware of the facility's policy on VA reporting and he had considered P2 a VA upon presenting to the emergency room. He was very concerned with the suspected abuse P2 had received and the attempted suicide as a result of that abuse. MD-B had contacted the county SW. MD-B was concerned for the safety and welfare of P2 and was seeking inpatient mental health placement. MD-B agreed the facility needed to re-educated staff on following the VA policy on reporting.

Review of the facility's revised November 2016 Vulnerable Adult policy indicated its purpose was to provide the facilities staff guidelines for reporting evidence of suspected maltreatment. All staff were required to report suspected, alleged or observed maltreatment/abuse to the MDH and the administrator and the DON immediately. A prevention plan was to have been incorporated into the patient's care plan that included specific measures that were needed to protect the VA from the risk of further abuse.

Based on interview and document review, the critical access hospital (CAH) failed to ensure a comprehensive list of services furnished under agreement, arrangement or contract had been maintained. This had the potential to affect all patients who received services at the CAH.

Findings include:

On 6/28/17, at 2:45 p.m. the quality manager (QM) indicated the CAH did not have a formal list of services provided through agreements or arrangements at that time.

On 6/29/17, at 8:10 a.m. the QM provided the CAH's current list of services provided through agreements or arrangements. The QM stated she had developed the list of contracted services that day. The CAH's Contracted Patient Care Provider Services list (undated) identified 24 company names. The CAH's contracted services list lacked information regarding whether the services were offered on or off site; whether there was any limit on the volume or frequency of services provided; and when the services were available.

Based on observation, interview and record review, the provider failed to appropriately assess, monitor and implement suicide precautions for 1 of 1 patient (P2) who presented to the emergency room (ER) with a failed suicide attempt and a known history of depression.

Findings include:

Review of the medical record revealed P-2 was brought to the ER on 6/25/17, for a failed suicide attempt at gunpoint with police intervention. The ED (emergency department) Provider Note dated 6/25/17, indicated P2 had made comments such as "has nothing to live for" and he feels like a "burden" to his family and wishes some days he would go to sleep and not wake up. He denied planning the attempt and was deemed not acutely suicidal, but had not indicated that he would not have harmed himself had he been discharged and left the hospital. The ED Provider note indicated P2 had a diagnosis of suicidal ideation, and had been be admitted to the hospital with possible transfer for inpatient mental health treatment for his safety. The note indicated a mental health hold would be put in place if P2 attempted to leave the hospital.

A physician (MD) progress noted dated 6/26/17, written by MD-B, indicated P-2's relationship with his son had become "Quite toxic, with [P2] the brunt of mental, emotional, financial abuse. Physical abuse possible as [P2] has had objects thrown at him. This is a significant change from [P2] 2-3 years ago. His son arrived on the scene about 2 years ago and since then [P2] mood and activity have decreased. In visiting with [P2], his son has taken away his phone, would not allow him to go golfing- which was [P2's] favorite summertime activity, as is also acquired [P2's] social security check and finances so that [P2] really is left quite helpless without recourse." MD-B noted he had placed a call to the local county social services for help.

Review of P2's admission nursing care plan printed on 6/27/17, revealed the goal of ineffective coping skills, and listed various interventions which included to educate on positive coping skills, and community resources. However, the care plan lacked documentation of any interventions related to P2's safety and suicide prevention.

Interview and record review on 6/27/17, at 11:00 a.m. with registered nurse (RN)-D revealed on 6/25/17, P-2 was admitted to the facility for a suicide attempt and was placed on suicide precautions by the admitting physician. There had been no interventions placed on his care plan related to suicide precautions. She indicated staff had not performed any precautions. She had indicated although he was placed in a room closest to the nursing station, she realized staff should have done more specific nursing interventions related to suicide risk.

Random observations on 6/27/17, from 11:05 a.m. through 2:30 p.m. of P2 revealed his room was next to the nurse's station. He seemed quite anxious about his potential discharge to an inpatient facility and would repeatedly ask staff for status updates of when or where he was going. Multiple visitors were observed going directly into the resident's room without stopping at the nurse's station. Staff had not asked visitors for any information that would identity the potential presence of the reported abusive family member.

During interview on 6/27/17, at 1:50 p.m. with the licensed social worker (LSW)-E, indicated her role was to assist with discharge planning for the facility. She met twice weekly with staff and discuss briefly any needs patients may have. The facility process was nursing staff were to have called her to alert her to any concerns related to social services. She was aware P2 was admitted for suicide attempt and depression but felt if staff needed her they would have called her. She was unsure of her role as the facilities social worker in acute assessment, but agreed that would have been a good opportunity to meet the psychosocial needs of P2 and assist the physician in mental health inpatient placement.

During interview on 6/27/17, at 2:20 p.m. with the director of nursing (DON) regarding the mental health status of P2, the DON indicated she she agreed staff should have placed P2 on suicide precautions as ordered, provided ongoing assessments, and placed interventions on the care plan. She also agreed social services needed to be involved to assist in meeting the psychosocial needs of P2 and that had not been done.

During interview on 6/28/17, at 1:20 p.m., MD-B, who was also the medical director for the facility, revealed he was not aware staff had not placed P2 on suicide precautions as ordered and agreed staff needed to follow the facility policy related to suicide for the safety and well-being of suicidal patients.

Review of the facility's May 2017, Care Plan policy indicated care plans were to be completed within 8 hours of admission and reviewed daily by an RN.

Review of the facility's revised May 2017 Suicide, Management of Patient policy indicated the first step was to treat the patient medically and plant interventions for care. The patient was to be assessed for risk factors and initiated a one to one (1:1) observation that included:
1) Removing all sharp or hazardous objects from the room.
2) Serving food on paper plates with plastic utensils.
3) Taking away shoelaces or belts and other potentially hazardous items.
4) Telling visitors not to leave unless the nurse approves.
5) Observe the patient taking his/her medication.
6) Restricting the patient to a limited area.
7) Using a room near the nurse's station.
8) Considering having the patient write and sign a no-harm contract.
9) Reassessing the patient at least once per shift regarding his/her suicidal thoughts and documenting that assessment.
10) Transferring the patient to another facility for care when appropriate.

Based on observation, interview and document review, the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services CFR 485.639. The CAH failed to ensure the safe use of electrocautery devices resulting in a risk for fire in the operating room and/or risk for patient burns for 1 of 1 patients (P1) observed during a surgical procedure where the surgeon and/or surgical staff failed to operate the electrocautery device as directed by hospital policy and manufacturer recommendation. The cumulative effect of this systemic problem resulted in the CAH's inability to ensure the provision of quality health care in a safe environment.

Findings include:

P1 was observed on 6/28/17, at 8:00 a.m. during a colpocleisis surgical procedure (closure of the vagina). P1 was observed to utilize oxygen during the surgical procedure. During the procedure, it was noted the use of Force 2 Electrosurgical Generator (a cautery pencil device) was utilized by medical doctor (MD)-A and was placed on top of P1's drape. MD-A failed to place the electrocautery device into the holster several times during the procedure as follows:

1) At 9:07 a.m. MD-A was observed to utilize the cautery pencil and placed it on top of P1's draped abdomen instead of the holster provided. At 9:08 a.m. the licensed practical nurse (LPN) placed a 4 by 4 gauze on top of the cautery tip. LPN-A picked up the cautery and placed it in the holster at 9:10 a.m. (after a total of 3 minutes resting on the patient's drape). LPN-A had to manually remove the gauze from the tip of the cautery due to the gauze sticking to the tip.
2) At 9:12 a.m. MD-A was observed to place the cautery pencil device on top of P1's draped upper abdomen instead of the holster provided. The cautery laid on the patient's drape until 9:14 a.m. when MD-A picked it up to utilize it (a total of 2 minutes resting on the patient's drape).
3) At 9:15 a.m. MD-A was observed to place the cautery pencil device on top of P1's drape near the upper abdomen instead of the holster provided. LPN-A again placed a 4 by 4 gauze on top of the cautery tip at 9:17 a.m.. MD-A picked the cautery up to utilize at 9:18 a.m. (a total of 3 minutes resting on the patients drape).

When interviewed on 6/28/17, at 9:45 a.m. the surgical coordinator (SC) indicated all surgical staff are trained annually regarding safe use of the electrocautery pencil and all staff were expected to place the cautery in the holster rather than on the drape after use.

Interview with LPN-A on 6/28/17, at 10:13 a.m. confirmed she should have recognized the cautery pencil on the drape sooner than she had. LPN-A also indicated she did not recall placing the gauze on the tip of the cautery during the above times and verified this could be a fire hazard. LPN-A further included the cautery pencil should be placed in the holster after use.

Interview with registered nurse (RN)-A on 6/28/17, at 10:20 a.m. confirmed she had been assisting during P1's surgical procedure, but did not observe the cautery pencil on the patient's drape during the above times. RN-A was aware that the cautery pencil should be placed in the holster when not in use.

Interview on 6/28/17, at 10:45 am with MD-A confirmed the cautery pencil had been placed on the drape several times during P1's surgical procedure and indicated that he would work on recognizing the importance of placing it in the holster after use.

A review of the hospital's incident/accident reports for the past year revealed no incidents of fire/injury had occurred related to the use of electro cautery devices.

Review of the facility's policy, Electrosurgical Unit Safety and Use dated 6/2016, included proper care and handling of the electrosurgical equipment (that included the pencil) is essential to patient and personnel safety. The policy indicated the active electrode should be placed in a holster at all times, when not in use and the active electrode tip shall be secure and free of charred tissue.

Review of the undated manufacturer's guidance for use of the Force 2 Electrosurgical Generator (cautery pencil), with the subject title "Warning" directed staff: "When not in use place active cautery equipment in a holster or in a clean, dry non-conductive, and highly visible area and not in contact with the patient. Inadvertent contact with a patient may result in burns. Fire Hazard: do not place active cautery equipment near or in contact with flammable materials (such as gauze or surgical drapes).This may cause a fire. Use the valleylab holster to hold electrosurgical pencils and accessories safely away from patients, personnel and surgical drapes. Do not place active instrument near or in contact with flammable materials such as gauze or surgical drapes. Electrosurgical instruments that are activated or hot from use can cause fire. When not in use, place the cautery pencil in a holster and safely away from flammable materials and patients."

Based on interview and document review, the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QAPI) projects were current, comprehensive and incorporated into the CAH's QAPI program for services provided through arrangement or agreement. This had the potential to affect all patients receiving services from the CAH.

Findings include:

On 6/28/17, at 2:10 p.m. the quality manager (QM) identified services provided to patients through arrangement or agreement. According to the QM, QAPI initiatives for the following services were not incorporated into the CAH's QAPI program.

Review of the CAH's Quality Committee meeting minutes from June 2016, to May 2017, lacked identified QAPI initiatives for services provided through arrangement or agreement for the following services: Madison ambulance, pharmedium, Cardinal Health Remote Order Entry Service, Omnicell Technologies, Voyager Radiology, DMS, CentraCare Heart and Vascular Imaging, CentraCare Cardiology, 7 Medical-PACS.

A policy titled, Organizational Quality Improvement Plan, revised 12/29/16, indicated each service area needed to identify one or more major monitoring and evaluation activities in their annual Service Area Quality Management Plan. Each service area was responsible for identifying opportunities to improve processes within their own area or between service area and those of other areas. In addition, the CAH identified the Plan Do Check Act methodology for undertaking performance improvement. This methodology identified potential improvements, or indicated the need for more focused review of the issues involved. It also allowed for checking the results of the improvement after implementation to ensure it produced the intended results.