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Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 06/11/10.

Throne, Paul

Based on review of medical staff credentialing records and interview, the critical access
hospital failed to establish a process for the granting of the clinical privilege in procedural sedation.

Failure to establish a process for the granting of the clinical privilege in procedural sedation risks patient injury through the ordering of procedural sedation by unqualified providers.

Findings include:

During review of medical staff credentialing records on 06/10/10, it was found that three non-anesthesia providers had requested and been granted the privilege in procedural sedation (MD 1 - MD3). None of the three credentialing records indicated qualification for the privilege through training, experience or education.

In an interview on 06/10/10, the medical staff coordinator stated that there was no hospital policy requiring specific training, experience or education before granting the procedural sedation privilege.

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure that complete written orders were obtained for blood/blood products administered to patients in 2 of 2 records reviewed (Patient #2, #3).

Failure to obtain complete written orders for blood/blood products risks administration errors and patient harm.

Findings:

1. Patient #2 was a 69 year-old patient admitted on 6/7/2010 for treatment of pneumonia (lung infection) and gastrointestinal (stomach and intestines) bleeding. Review of the medical record revealed that a physician had completed an electronic form to order 2 units of packed red blood cells and 2 units of fresh frozen plasma from the laboratory. Review of blood administration documentation revealed that Patient #1 received 4 units of packed red blood cells. There was no medical order for administration of blood or blood products in the medical record.

2. Patient #3 was a 71 year-old patient admitted to a swing bed on 12/31/2009 for "strengthening" following a hospital stay at another facility. Patient #3 received 2 units of packed red blood cells on 1/11/2010. Review of the medical record revealed that the physician's order stated "administer blood" but did not include what type of blood product to administer, how many units, or how fast to infuse the blood product.

3. An interview with the director of quality on 6/11/2010 revealed that the hospital did not have a policy that defined what information should be included in a physician's order for blood or blood products.

Based on record review, review of policies and procedures, and interview, the hospital failed to develop a systematic process for referring patients at nutritional risk to a dietician for a nutritional assessment in 1 of 2 records reviewed (Patient #1).

Failure to assess, plan, and provide nutritional care for patients with inadequate intake risks malnutrition of patients and impaired healing.

Findings:

Patient #1 was a 65 year-old patient admitted on 6/7/2010 for treatment of pneumonia and low blood sodium levels. Review of the nursing admission assessment for nutritional concerns revealed that the patient was on a special diet of clear liquids, and was having problems with abdominal distention. Nursing staff assessed the patient's nutritional status as not within normal parameters.

Review of the hospital's policy entitled "Coulee Medical Center Weight/Nutrition Policy and Procedure" (no effective date) revealed that there was not a clearly defined process for referring patients to the dietician for a nutritional assessment based on the nutritional risk screen.

An interview with the director of quality confirmed the above findings.

Item #1 - Medication prepacks

1. Based on interview, record review, and review of policy and procedure, the facility failed to develop and implement a policy and procedure for emergency outpatient medication prepacks that included controlled substances that met the requirements in Chapter 246-873 Pharmacy - Hospital Standards.

Failure to do so places patients at risk for medication errors, and unrecognized adverse drug events, and risks tampering and diversion of controlled substances.

Reference:
WAC 246-873-060 Emergency Outpatient Medications

The director of pharmacy of a hospital shall, in concert with the appropriate committee of the hospital medical staff, develop policies and procedures, which shall be implemented, to provide emergency pharmaceuticals to outpatients during hours when normal community or hospital pharmacy services are not available ....

Such policies shall allow the designated registered nurse(s) to deliver medications other than controlled substances ....

(7) The procedures outlined in this rule may not be used for controlled substances except at the following rural hospitals which met all three of the rural access project criteria on May 17, 1989:

Lake Chelan Community Hospital
St. Joseph ' s Hospital
Whitman Community Hospital
Lincoln Hospital
Dayton General Hospital
Ocean Beach Hospital
Newport Community Hospital
Jefferson General Hospital
Ritzville Memorial Hospital
Willapa Harbor Hospital

Findings:

a. An interview with Staff member #1 (S1) on 6/10/2010 revealed that nurses dispensed home medication packs from the electronic system for emergency department patients. Some of the home medication packs included controlled substances, such as Vicodin and Percocet.

b. Review of the "Prepack Dispensing Log" on 6/10/2010, located in the emergency department, revealed that Percocet prepacks had been dispensed by nursing staff on 5/31/2010 and 6/8/2010, and Vicodin prepacks had been dispensed by nursing staff on 6/1/2010 and 6/9/2010.

c. Review of the Hospital's policy entitled "Proposed ER Prepack Procedure" (no effective date) revealed that the policy did not address the issue of dispensing home medication prepacks that included controlled substances.

d. An interview with the interim director of nursing services on 6/11/2010 confirmed the above findings.


Item #2 - Unlabeled Syringes

2. Based on observation, the Hospital failed to ensure that pre-drawn syringes of medication were labeled according to acceptable standards of practice.

Failure to label pre-drawn syringes of medication risks medication errors and patient harm.

Findings:

a. On 6/11/2010 at 8:15AM, surveyor #14866 observed a colonoscopy (an internal examination of the colon). Before the patient entered the procedure area the surveyor observed CRNA #1 draw up a milky white fluid into a syringe and place the syringe into an injection device. The syringe was not labeled with the name of the fluid. The CRNA then left the area and returned later.

b. An interview with the hospital risk manager on 6/11/2010 revealed that the hospital did not have a policy and procedure regarding the labeling of pre-drawn medications.


Item #3 - Wastage of Controlled Substances

3. Based on observation and interview, the Hospital failed to develop and implement a policy and procedure guiding staff in the proper procedure, as defined by law, for wastage of controlled substances (narcotics).

Failure to assure consistent and proper oversight for wastage of controlled substances increases the potential for drug diversion or tampering, and places patients at risk of receiving sub-therapeutic treatments, and attaining suboptimal sedation and/or recovery.

Reference:

WAC 246-873-080 Drug procurement, distribution and control

(7) Controlled substance accountability. The director of pharmacy shall establish effective procedures and maintain adequate records regarding use and accountability of controlled substances, and such other drugs as appropriate, in compliance with state and federal laws and regulations

(d) When it is necessary to destroy small amounts of controlled substances following the administration of a dose by a nurse, the destruction shall be witnessed by a second nurse who shall countersign the records of destruction.

Findings:

a. On 6/11/2010 at the conclusion of a patient's procedure, surveyor #14866 observed CRNA #1 standing at the sharps disposal container which was attached to the wall of the procedure area. CRNA #1 stated "I'm wasting 3 Versed." The surgery department manager had her back turned to CRNA #1 at the time, and stated "OK," and appeared to proceed to document the wastage of the narcotic.

b. Upon interview, the hospital utilization review nurse stated that it was hospital practice when wasting narcotics to place the entire syringe containing the wasted drug into the sharps container without releasing the drug from the syringe prior to disposing of the syringe.

c. On 6/11/2010, upon review of hospital policies, the hospital risk manager was unable to locate a policy describing proper technique for wasting narcotics.

Based on record review, interview, and review of policy and procedure, the hospital failed to develop an individualized plan for patient care according to hospital policy for 2 of 14 records reviewed (Patient #4, #5).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patients needs.

Findings:

1. The hospital's policy and procedure entitled "Nursing Documentation Policy" (no effective date) stated that "a care plan will be made out on each patient at the time of admission. This plan will be individualized and updated as changes occur."

2. Review of fourteen patient care records revealed the following:

a. Patient #4 was a 24 year-old patient admitted on 6/8/2010 for labor induction. Review of the medical record on 6/9/2010 revealed that no patient care plan had been developed and implemented.

b. Patient #5 was a 43 year-old patient admitted on 6/9/2010 for labor induction. Review of the medical record on 6/11/2010 revealed that the patient's plan of care had not been updated to include care of the post partum patient.

Throne, Paul
Based on interview and review of performance improvement documentation, the critical access hospital failed to systematically assess medication errors for patterns and trends.

Failure to systematically assess medication errors limits the hospital's ability to prevent future errors and reduce risk of patient harm.

Findings include:

During review of performance improvement data and an interview on 06/10/10, the hospital performance improvement manager stated that the hospital did not systematically analyze aggregate data on medication errors to determine if the errors had a common cause or if certain types of errors were increasing in number and frequency. There was no method for using analysis of errors to discover major patterns and trends that could lead to action plans to improve medication delivery systems and prevent recurrence of errors. Review of performance improvement data confirmed that there was no analysis of aggregate medication errors.