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Based on document review and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure all emergency airway equipment was working properly, potentially affecting all patients requiring an emergency airway in the Emergency Department (ED).
Findings include:

1. On 1/17/17 at 12:00 PM, a tour of the ED was conducted. During the tour, it was observed in the emergency supply cart, a laryngoscope handle that would not provide power to a laryngoscope blade light. The (2) C batteries were removed and replaced with all four replacement batteries laying next to the laryngoscope blades. Those batteries were unable to provide power to the blade light. Two batteries from the trauma room were placed in the laryngoscope handle and the blade light worked.

2. The "Crash Cart Checklist" form for the month of January 2017 was reviewed on 1/17/17 at 12:10 PM. Under "Crash Cart Checklist, check laryngoscope handle and all blades the 1st of each month." Documentation indicated the laryngoscope was checked on 1/4/17 and operating properly.

3. On 1/17/17 at 12:10 PM, an interview with Emergency Department Manager (E #6). E #6 confirmed that all the batteries in the emergency supply cart were dead. E#6 also confirmed the "Crash Cart Checklist" was initialed by ED staff, indicating the laryngoscope was operating properly on 1/4/17.

Based on policy and procedure, record review and staff interview, it was determined in 1 of 3 (Pt # 22) blood transfusion records reviewed, the CAH failed to ensure vital signs were completed per policy. This failure has the potential to affect all patients receiving blood transfusions.
Findings include:

1. On 1/18/17 at 3:30 PM,the CAH policy dated, 10/15, titled "BLOOD TRANSFUSION OF PLASMA, PLATELETS, CRYOPRECIPITATE & ALBUMIN" was reviewed. Under "PROCEDURE: Key Points: a. VITAL SIGNS SHOULD BE TAKEN: pre-transfusion then 15 minutes after initiation of blood then every hour and post-transfusion."

2. On 1/18/17 at 4:00 PM, the medical record of Pt #22 was reviewed. Pt #22 was admitted to special care unit on 10/24/16 with diagnoses of anemia and dizziness. On 10/24/16, Pt #22's hemoglobin was 6.7. Two units of blood was ordered for transfusion. The first unit was completed on 10/25/16. The second unit was started on 10/25/16 at 0525. Vital signs were completed at 0525, 0621, 0800, 0825 and 1000. There was no documentation to indicate vital signs were taken between 0621 and 0800. Therefore, the hourly vital signs were not completed.

3. On 1/19/17 at 9:00 AM, an interview was conducted with the Inpatient Manager (E#4). E#4 reviewed Pt #22's medical record and confirmed the vital signs were not taken every hour per policy.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on January 25 - 26, 2017, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure patient-care equipment was properly stored, potentially affecting all patients receiving care at the CAH.
Findings include:

1. On 1/17/17 at 10:45 AM, a tour of the operating room was conducted with the operating room supervisor (E #3). During the tour, it was observed in a hallway corner, an unsecured oxygen tank.

2. On 1/18/17 at 4:00 PM, the CAH policy " Utility Systems Management" revised 10/15 was reviewed. Under "4. Portable O 2 (oxygen), Nitrous, ect. tanks shall be securely mounted when in use. All storage tanks shall be stored in the cylinder storage rooms chained or securely mounted to prevent tipping."

3. On 1/17/17 at 11:15 AM, an interview was conducted with E #3. E#3 confirmed the oxygen tank was not secured to a wall or in an oxygen tank stand.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on January 25 - 26, 2017, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review and staff interview, it was determined the CAH failed to ensure policies addressing reprocessing of patient care equipment were specific and followed current practices to ensure prevention of infection. This failure has the potential to affect all patients having ophthalmology and otolaryngology surgeries.
Findings include:
1. A review of the policy titled "Immediate Use Steam Sterilization" last review date 10/16, was completed on 1/17/17 at 3:00 PM. The CAH policy indicates under "POLICY: ... Immediate use steam sterilization should be avoided whenever possible."
2. A tour of the surgery department sterilization area was conducted with surgical technician (E#9) on 1/17/17 at 11:00 AM. E #9 was asked if staff perform immediate use steam sterilization (IUSS), E#9 stated " Yes, we use it for eye trays, tonsillectomy trays and T tube trays " (tympanostomy with tube placement). E#9 was asked how often the process is performed, E#9 replied " I keep a monthly record of the immediate use, but we normally use the short cycle most days we do these surgeries. We have discussed the need for additional instruments for these procedures and I have been gathering supplies we already have to see what is needed to complete the trays. I have the estimates for buying what we need but this has not gone for approval yet. "
3. A review of the " 3013 Prevacuum Steam Sterilizer " form was completed on 1/17/17 at 12:15 PM. The form provides a column with monthly totals of the number of times IUSS is performed. The average number of times per month instruments are sterilized using the IUSS process for the year 2016 is 11. The range of times varied from 5 to 19 times per month with surgeries of this type being performed 39 days in the 12 month period.
4. An interview was conducted with the operating room manager (E#3) on 1/17/17 at 11:50 AM. E#3 also reported they have discussed the need for more instruments and indicated they are waiting for the next meeting of the board for approval. E#3 agreed they need additional supplies and the IUSS should be used in isolated situations.

Based on document review, observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure food items were discarded before the expiration date, potentially affecting the all patients receiving dietary services.
Findings include:

1. On 1/17/17 at 10:45 AM, a tour of the surgery department was conducted with the operating room supervisor (E #3). During the tour, it was observed in the refrigerator (1), 4 fluid ounce container of cranberry juice with an expiration date of November 16, 2016. There were approximately twenty other juice containers in the refrigerator that had not expired.

2. The CAH policy "Designated Areas For Storage" revised 11/16, was reviewed on 1/18/17 at 8:00 AM. The policy indicated "All food is dated and rotated so that the first in will be the first out."

3. On 1/18/17 at 9:00 AM, an interview was conducted with E#3. E #3 confirmed the cranberry juice had expired and stated "It should have been removed from the patient care area."

4. On 1/17/17 at 3:30 PM, a tour of the cardiac rehab area was conducted with (certified respiratory technician) E#11. During the tour, it was observed in a food storage cabinet, Nutragrain fruit bars and individual peanut butter containers with no date of expiration or use by date.

5. On 1/18/17 at 9:30 AM, a tour of the inpatient medical/surgical floor was conducted with the inpatient manager (E#4). During the tour, it was observed in the patient food supply room, several small plastic bags with individual peanut butter containers. The date on the outside of the bag was 1/17/17, indicating when the item was delivered by dietary. There was no date of expiration or use by date.

6. An interview was conducted with the dietician (E#5) on 1/18/17 at 10:30 AM. E#5 checked the items in question and agreed the Nutragrain bars did not have an expiration date on each bar. E#5 agreed the date of delivery marked on the bags with the peanut butter containers was not useful in determining expiration or safe use when providing these items to patients. E#5 reported the items needed a specific date when these were safe for use.

Based on document review and staff interview, it was determined for 1 of 3 (Pt #7) patient, in the Emergency Department (ED) who left Against Medical Advice (AMA), the CAH failed to ensure the medical records were completed per policy.
Findings include:

1. On 1/17/17 at 2:00 PM, the medical record of Pt #7 was reviewed. Pt #7 was admitted to the ED on 1/13/16 and left the ED, against medical advice, on 1/13/16. There was no documentation to indicate Pt #7 signed an Against Medical Advice form or refused to sign the form.

2. On 1/17/17 at 2:10 PM, the CAH policy "Against Medical Advice" no revision date, was reviewed. Under "3. Have the patient/legal representative sign the form......Place on chart. 5. If the patient/legal representative refuses to sign the form.......document on the form and the patient chart the reason the form was not signed."

3. On 1/17/17 at 2:30 PM, an interview with E #6 was conducted. E #6 reviewed Pt #7's ED record. E#6 stated, "The medical record does not contain an Against Medical Advice form and should have."