HospitalInspections.org

Based on review of personnel records and interview, the facility failed to ensure background studies were completed for 2 of 2 pool staff (PS-A, PS-B) and 1 of 1 contracted staff (CS-A) that currently provided direct care services to patients at the Critical Access Hospital (CAH). Findings include:

PS-A had been hired as a temporary pool surgical technician on 9/7/10, and was currently providing direct patient care services. However, the personnel record lacked evidence of a background study completion.

PS-B had been hired as a temporary pool registered nurse (RN) on 10/23/09, and had been providing direct patient care services intermittently. However, the personnel record lacked evidence of a background study completion.

CS-A had been contracted approximately 6-7 years ago and had been providing direct patient care with intermittent speech therapy services. However, the personnel record lacked evidence of a background study completion.

On 9/16/10, at 10:15 a.m., the human resources manager verified these findings.

Based on observation and interview the facility failed to maintain a physical plant in a manner that ensured patient safety. Finding include,

The fireplace place in the family and patient waiting area had an unsafe surface temperature.
During the environmental tour on 9/16/10, at 10:20 a.m. the plant operations manager was asked to assess the temperature of the propane fire place in the family and patient waiting area. When the manager placed his hand on the glass surface he stated "I totally agree, way to hot". The manager used a surface thermometer and obtain a temp of 260 degrees.
The manager shut off the fireplace and disconnected the propane. The manger indicated he had not heard of any concerns regarding the fireplace.

At 10:55 a.m. the director of nursing placed her hand on the surface of the fireplace and stated "It's still hot" . The director indicated that no one had been burnt by the fireplace and that staff had not informed her of any concerns.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure that all drugs and biologicals were secure in 2 of 7 departments and in 1 of 2 offsite clinics utilizing medications. Findings include:


On 9/14/10, at 3:00 p.m. the emergency department (ED) was observed to have several access entrances. Most of the entrance accesses were secured with a coded lock system. However, an elevator from the circular main hospital lobby was observed to have unmonitored access into the ED. Staff at the nurses station down another short entrance hallway adjacent to the ED were not able to maintain visual observations of anyone entering the elevator or the ED from the elevator.

During the tour of the ED at this time with the director of nursing (DON), containers of respiratory medications were observed in unlocked cupboards in the emergency rooms. Medications in the trays included: Albuterol Nebs and solution, Ipratropium Nebs, and sodium chloride Nebs. At this time, the DON verified the medications were not secure.

On 9/15/10, at 2:50 p.m., the surveyor stepped out into the ED from the lobby elevator. The ED was observed to be empty with no staff present or in view from the ED. In addition, the doorway connecting the physician consultation room and a waiting room was observed to be open. The waiting room opened into the hospitals main circular lobby and could not be visualized from the nurses station. At this time, the red crash cart was observed to be open and unsecured. Injectable and oral medications maintained in the cart included: Adenosine, Albuterol Nebs, aminophylline, Amiodarone, atropine sulfate, calcium chloride, Decadron, Valium, Lanoxin, Benadryl, dobutamine, edrophonium, epinephrine, flumazenil, furosemide, glucagon, Haldol, heparin, metoprolol, Solu-Medrol, magnesium sulfate, Versed, Narcan, Pronestyl, Inderal, Compazine, sodium bicarb, Vasopressin, and Verapamil. At 3:00 p.m., the surveyor requested the DON to come into the ED. At this time, the DON verified the medications were not secure and were not able to be visually monitored at the nursing station. The DON stated housekeeping must have left the door open and unlocked between the physician consult room and the waiting room. The DON verified the video cameras did not monitor the elevator entrance into the ED.

During the tour of the Rehabilitation Department on 9/14/10, an unlocked medication was found in the treatment room. The medication was Hydrocerin Cream. The Director of Rehabilitation indicated that the medication was in all the three treatment rooms.

According to the the policy "Storage and Maintenance of Drugs" dated as reviewed in 2008, "All drugs will be kept in areas away from patient/visitor accessibility" and "Drugs necessary for the daily function of each unit will be stored in these areas (e.g. ER,.....Crash Carts, etc.) and locked up as appropriate."

During the tour of the off site Marcell clinic on 9/15/10, at 4:05 p.m., biologicals were observed to be stored in a refrigerator in a patient exam room one. The biologicals included: RotaTeq, IPOL, Gardasil, Prevnar, Adacel, Fluzone, Pediarix, Engerix-B, Havrix, Tripedia, ActHib, Varivax, Decavac, MMR II, and Pneumovax vaccines. Unsecured medications were also observed in patient exam room two that included: erythromycin, Neo-Synephrine spray solution, and Antipyrine and Benzocaine ear drops. At this time, the RN director of the Marcell clinic verified patients used the exam rooms and the biologicals and medications were not secured from unauthorized access.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated with a timed and dated signature for 11 of 20 ( P8, P17, P1, P2, P3, P6, P7, P10, P11, P15, P20) inpatient records reviewed ; for 2 of 5 (OP25, OP 24)outpatient surgical records and for 4 of 4 (SW4, SB5, SB22, SB23) residents in swing bed. Findings include:

P8 was an inpatient from 1/5/10 to 1/12/10, for pneumonia and dehydration. The admission orders of 1/5/10, progress notes of 1/6/10, 1/7/10 and 1/8/10 were not timed by the physician.

P17 was an inpatient from 12/8/09 to 12/11/09, for knee surgery. The per-op orders of 12/8/09 by surgeon-B and the orders of 12/9/09 and the post operative note by Certified Registered Nurse Anesthetist (CRNA) were not timed when signed.



12828

P1 was admitted to the CAH on 9/13/10. The physician orders dated 9/13/10, and 9/14/10, and the physician progress notes dated 9/14/10, 9/15/10, and 9/16/10, lacked the time of the entries.

P2 was admitted to the CAH on 9/14/10. Physician orders dated 9/14/10, 9/15/10, and 9/16/10, and the physician progress notes dated 9/15/10, and 9/16/10 lacked the time of the entries.

P3 was admitted to the CAH on 9/13/10. Physician orders dated 9/13/10, and 9/15/10, and physician progress notes dated 9/14/10 and 9/15/10, lacked the time of the entries.

P6 was admitted to the CAH on 10/1/09. Physician progress notes dated 10/1/09, 10/2/09, 10/3/09, 10/4/09, 10/5/09, and 10/6/09, lacked the time of the entries.

P7 was admitted to the CAH on 10/21/09. Physician orders dated 10/21/09, and 10/22/09, and physician progress notes dated 10/22/09, lacked the time of the entries.

P10 was admitted to the CAH on 4/19/10. Physician progress notes dated 4/21/10, and 4/23/10, lacked the time of the entries.

P11 was admitted to the CAH on 5/26/10. Physician orders dated 5/26/10,5/27/10, and 5/28/10, and physician progress notes dated 5/27/10, 5/28/10, 5/29/10, and 5/30/10, lacked the time of the entries.

P15 was admitted to the CAH on 12/8/09. Three physician orders dated 12/8/09, lacked the time of the entries.

P20 was admitted to the CAH on 4/23/10. Physician orders dated 4/23/10, lacked the time of the entry, and the history and physical dictated 4/23/10, had not been signed.

OP25 had an order for a CT scan of abdomen and pelvis dated 8/18/2010 that was not timed when the midlevel signed.

OP24 had outpatient surgery on 9/15/2010. The Pre-Op and Recovery Room Anesthesia Orders were not timed when the CRNA when signed on 9/15/2010. The times of entries on the Surgical Safety Checklist during surgery on 9/15/2010 were not recorded.



20012

SB4 whose diagnoses included Congestive Hear Failure was admitted to a swing bed on 9/3/10. Physician orders dated 9/4, 9/5 ,9/6, 9/8, 9/9, 9/13, 9/14, and 9/15/10 lacked the time the entry was made by the physicians. In addition, physician's progress notes dated 9/4, 9/6, 9/9, 9/13, 9/14, and 9/16/10 also lacked the time the entry was made.

SB5, whose diagnoses included a recent Gastro Intestinal bleed, was admitted to a swing bed on 9/3/10. Physician orders dated 9/8, 9/13, 9/14, and 9/15/10 lacked the time the entry was made by the physicians. In addition, physician's progress notes dated 9/7, 9/8, and 9/13/10 also lacked the time the entry was made.

SB22, whose diagnoses included osteomyelitis was admitted to a swing bed on 9/13/10.
Physician orders dated 9/13/10 and 9/16/10 lacked the time the entry was made by the physicians. In addition, a physician's progress note dated 9/15/10 also lacked the time the entry was made.

SB23 was admitted to swing bed on 1/12/2010 and the swing beds admission orders lacked the time the physician signed. In addition, a physician's order dated 1/14/2010 was not timed then the order was authenticated.

The CAH policy "Physician Orders" dated as reviewed 2008, directed, "All orders for treatment shall be in writing and include the date and time and signature of the Practitioner."

On 9/16/10 at 2:50 p.m., the director of nursing verified these findings.

Based on review of surgical privileges and staff interview, the Critical Access Hospital (CAH) failed to assure the current roster for 8 of 8 (S-A, S-B, S-C, S-D, S-E, S-F, S-G, S-H) surgeons with surgical privileges was current and available in the surgical suite and area where scheduling of surgeries was done. Findings include:

An updated and current surgical privilege roster was not available to surgical staff in the surgical suite or in the area where scheduling occurred. On 9/15/10, at 8:40 a.m. the roster was in the procedure room of the surgical suite and was not current. It was noted the roster delineating each practitioner's surgical privileges was not current. For example, the delineation of privileges for S-A was dated 1973 and S-F was dated 1/11/02. For S-B, S-C, S-D, and S-E privileges were undated.

On 9/15/2010, at 9:00 a.m. it was confirmed by the Surgical RN-A that the roster in the OR area lacked the most recent delineation of surgical privileges for the providers listed. It was also indicated that some of the practitioners listed in the roster no longer provided services for the CAH.

Review of medical staff credentials provided by the CAH administration revealed S-A had current surgical privileges granted by the governing body on 10/15/09. Other current privileges had been granted for the following surgeons: S-B on 9/3/2009; S-C on 9/9/2009; S-D on 9/9/2009; S-E on 11/6/2009; S-E on 9-10-2009; S-F on 9-10-2009; S-G on 9/11/2009; S-H on 9/8/2009. However, this information had not been provided in written form to be available to the OR staff.

Based on record review and interview the facility failed to evaluate all patient care services, the swing bed, organ procurement, off-site clinics and laboratory services in the quality assurance program. Findings include:

The Director of Nursing was interviewed at 11:00 a.m. on 9/16/10, and verified that the facility's swing bed and organ procurement services did not have any formal evaluation and quality assurance project.

During a visit of the two off-site clinic on 9/15/10, the manager of the clinics was conducting quality assurance activities. However, these activities were not incorporated into the facility wide quality assurance plan and were not evaluated.


12828

During the tour of the laboratory department on 9/14/10, at 2:00 p.m., with the laboratory director, no current or ongoing quality assurance (QA) activity was evidenced. At this time, the laboratory directed stated he had completed the last project in August of 2009. He added the project had been a "10 minute fix." He verified he had not participated in any current QA since that time and was not aware of any QA the laboratory was currently involved in with other departments.


The CAH utilized a volunteer ambulance department. On 9/15/10, at 2:35 p.m., the ambulance head volunteer stated he had not been involved with any QA activity. He added the DON (director of nursing) had talked to him before about QA being needed. He stated it had "just fell by the wayside."