HospitalInspections.org

Based on record review and interviews the Critical Access Hospital (CAH) failed to ensure that patients receive information regarding advance directives (written instruction, such as a living will or durable power of attorney for healthcare),and that information was not provided to patients regarding advanced directives when requested. This affected 5 of 37 patients reviewed. CAH census was 10.

Findings are:

Record review revealed 5 out of 37 (Patients #5, #14, #15, #26, #31) did not have advance directive information assessed or advanced directive information provided when requested.

Review of Advanced Directives policy, last revised 4/2019, revealed that "advanced directives will be assessed during the admission process for inpatient hospital stays."

Interview with Vice President of Clinical Services (VPCS) on 3/3/2022 at 9:12 AM confirmed that if a patient would like more information regarding advanced directives, that Social Work would give the patient additional information and document in the electronic medical record. VPCS did not know why staff would document that a patient would like more information about advanced directives and not provide that information.

Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance (PM) according to manufacturer's guidelines for 3 of 18 sampled pieces of medical equipment.

Findings include:

Observation of Radiology Department on 3/1/2022 at 8:25 AM revealed blanket warmer used to warm blankets for patient use did not have biomedical sticker present to indicate preventive maintenance program.

Interview with Coordinator of Diagnostic Imaging on3/1/2022 at 8:25 AM confirmed that there was no biomedical sticker on blanket warmer or temperature log being recorded.

Observation of the Surgery Department on 3/1/2022 at 9:45 AM revealed the smoke evacuator (a machine that captures and filters smoke generated during surgical procedures) and Medivator scope buddy plus (a machine used to flush scope in a consistent and reliable means) did not have biomedical stickers present to indicate preventive maintenance being performed.

Review of Medical Equipment Management policy, last revised 05/2021, revealed "an evaluation of the effectiveness, scope, performance, and the objectives for the medical equipment management program will be conducted annually."

Interview with Surgery Supervisor on 3/1/2022 at 9:45 AM confirmed that smoke evacuator and Medivator scope buddy plus did not have biomedical stickers.

Interview with Lab Personnel G, on 3/2/2022 at 1:00 PM confirmed that the blanket warmer, smoke evacuator and, Medivator scope buddy plus were not on the preventive maintenance program.

Based on observation, interview and record review the Critical Access Hospital (CAH) failed to have a required information on the operating room register, the required emergency medical equipment available in 2 of 2 operating rooms, to ensure that outdated supplies were not available for patient use in 3 of 10 areas, to ensure that surgical medical records had all required documentation. This failed practice has the potential to effect all patients at the CAH. There were 363 surgical cases in fiscal year 21.

Findings are:

A. Record review of operating room register revealed did not have all required information for operating room register. Information missing included total time of operation, name of surgery assistants, and pre and post-op diagnosis.

Interview with Surgery Nurse F and Surgery Supervisor on 3/1/2022 at 9:50 AM confirmed that the operating room register was missing total time of operation, name of surgery assistants, and pre and post-op diagnosis.

Interview with Surgery Supervisor on 3/1/22 at 3:00 PM confirmed that the CAH did not have an operation log book and were unable to pull all information needed from electronic health record program.

B. Observation of operating rooms #1 and #2 on 3/1/2022 at 9:35 AM revealed a lack of a tracheotomy set and a defibrillator was not readily available in 2 of 2 operating rooms.

Interview with Surgery Supervisor on 3/1/2022 at 9:35 AM confirmed that there was a lack of a tracheotomy set and a defibrillator readily available.

Interview with Surgery Supervisor on 3/1/2022 at 2:35 PM confirmed that the CAH did not have a policy for emergency equipment required in the operating room.

C. Observation on 3/1/2022 at 9:35 AM revealed outdated supplies in anesthesia carts in 2 of 2 operating rooms, anesthesia cupboard in operating room #1, and the anesthesia cart in the Emergency Department Trauma Room.
Outdated supplies include:

Anesthesia Cart OR #1:
11- 27G 3.5 inch spinal needles

Anesthesia Cupboard OR #1:
Endotracheal tube packaged opened with syringe attached and stylet inserted into tube

Anesthesia Cart OR #2:
5-Nasopharyngeal Airway expiration date 2019
4- King Mask size 5 expiration date 2/2021

Anesthesia Cart in Trauma Room in Emergency Department:
1 tub lubricating Jelly expiration date 2014
1 Tuberculin Syringe expiration date 12/21
Open Mac 3 blade package in drawer

Interview with Surgery Nurse F on 3/1/2022 at 10:07 AM confirmed the outdated anesthesia supplies. Surgery Nurse F also confirmed that anesthesia is responsible for checking anesthesia supplies for outdates.

Interview with CRNA on 3/3/2022 at 10:40 AM confirmed that anesthesia does not have a process for checking outdates of supplies.

D. Record review of surgery charts revealed that 1 (Patient 28) out 6 charts were missing documentation. Documentation missing included a post-op anesthesia evaluation and patient disposition on discharge.

Interview with Certified Registered nurse Anesthetist (CRNA) on 3/3/22 at 10:32 AM confirmed that anesthesia performs a post-op anesthesia evaluation on every surgery patient. CRNA confirmed that Patient 28's medical record is missing post-op anesthesia evaluation.

Interview with Surgery Nurse H on 3/3/22 at 10:40 AM confirmed that Patient 28's medical record is missing discharge disposition. Surgery Nurse H confirmed that staff did not enter information into electronic medical record.

C-1608
Based on staff interviews and record review, the Critical Access Hospital, (CAH), failed to provide residents with policies pertaining to skilled nursing care for swing bed patients. This failed practice had the potential to effect all swing bed patients. Swing bed admissions for FY2021 were 90, total.

Findings Include:
Record review of policy and procedure, "Scope of Services Level of Care Provided in Skilled Care Swing Beds", last revised 07/2021, page 2, B, 7 states "once patient receives Swing Bed policies, patient or responsible party will sign "Swing Bed Acknowledgement" and add signed document to patient's chart". Record reviews for 5 of 5 swing bed patients lacked evidence of this form.

Interview with VP of Patient Care Services on 3/2/22 at 9:00 am revealed that swing bed admission policies were not being given out as per policy nor was an acknowledgement form being signed. She stated "no, we are not doing that".

Interview with Lead Health Information Management, on 3/2/22 at 9:30 am revealed that this form was unidentifiable in their electronic medical record, (EMR).

Interview with swing bed patient on 2/28 at 12:30 pm, patient stated that he does not remember getting any patient care polices upon admission to swing bed care at the CAH.