HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of ten patients. Based on document review and staff interview, the CAH failed to assure a mid-level practitioner participates in the development, implementation and review of the CAH's policies.

Findings include:

- The CAH's annual program evaluation, reviewed on 8/1/12 at 2:00pm revealed patient care policies were reviewed 10/24/11. The manuals and program evaluation lacked evidence of a physician assistant or nurse practitioner participation in the review.

- Staff J, interviewed on 8/1/12 at 3:00pm confirmed the CAH's documentation of policy development, review and implementation lacked evidence of a mid-level practitioner's participation.

The CAH failed to assure a mid-level practitioner participates in the development and review of patient care policies.

The Critical Access Hospital (CAH) reported a census of 10 patients. Based on observation, policy review, manufacturer's guidelines, and staff interviews the CAH failed to assure the safe, secure storage of drugs in one of one medication room. The CAH failed to ensure outdated drugs and biologicals were not available for patient use in one of three fluid warming cabinets.

Findings include:

- The CAH's policy "Scheduled (Narcotics) Medications" reviewed on 7/31/12 at 8:45am directed, "...all scheduled medications will be accounted for ...All scheduled medications leaving or returning to the pharmacy will be documented in the narcotic log ...All scheduled medication used on the patient floor will be secured in Pyxis ( a medication dispensing machine) cubies..."

- The manufacturer's information sheet for carpujet (a vial used to provide a single dose of medication) reviewed on 7/31/12 at 8:45am directed "...unit dose pak-ampuls...no preservatives are added to the ampuls or carpujet sterile cartridge units..."

- Observation on 7/30/12 at 1:40pm revealed a cabinet in the northeast corner of the medication room. The cabinet contained a two partially used carpujet (a vial used to provide a single dose of medication). The label on one carpujet indicated the vial contained Lorazapam (an antianxiety drug) 2mg (milligrams) per ml (milliliter) with a piece of tape with patient #21's name, dated 7/29. The carpujet contained ? ml of a clear liquid. The second carpujet indicated the vial contained Morphine Sulfate 10mg/ml with a piece of taped with patient #21's name, dated 7/27. The carpujet contained 0.2ml of a clear liquid.

Staff B interviewed on 7/30/12 at 1:40pm acknowledged the partially used carpujets and the RN (Registered Nurse) failed to secure narcotics from abuse and could not assure the liquid in the carpujets contained the labeled narcotic medications. Staff B acknowledged the RN failed to follow the CAH's policy for secured narcotic medications.

- Observation on 7/30/12 at 1:40pm of the cabinet in the northeast corner of the medication room revealed Levemir (insulin) Flex Pen 100 units per ml which lacked a label indicating the patient who the Levemir Flex Pen belonged.

Staff B interviewed on 7/30/12 at 1:40pm acknowledged the unlabeled Levemir Flex Pen and the CAH failed to have a policy for single patient use insulin pens.

- The CAH's policy "Insulin" reviewed on 7/31/12 at 8:45am directed "...All Vials will be discarded 28 days after the initial opening...any vial found unlabeled will be discarded..."

- Observation on 7/30/12 at 1:40pm of the cabinet in the northeast corner of the medication room revealed an open vial of Humulin 70/30 with a date of 7/12.

Staff B interviewed on 7/30/12 at 1:40pm acknowledged the Humulin 70/30 insulin lacked a clear date when opened.

- The manufacturer's information sheet for Hospira intravenous (IV) and irrigation solutions reviewed on 8/1/12 at 11:30am directed "... solution for injection and irrigation may be warmed up to temperatures not exceeding 40 degrees centigrade (104 degrees Fahrenheit) and for a period no longer than two weeks (14 days)..."

- Observation in the surgical suite sub-sterile area on 8/1/12 at 7:55am revealed a warming cabinet. The temperature of the warming cabinet registered 98 degrees Fahrenheit. The warming cabinet contained the following:
1. One 1000cc container of Normal Saline IV solution.
2. Two 1000cc containers of Lactated Ringers IV solution.
3. One 500cc containers of Lactated Ringers IV solution.
4. Five 500cc containers of Sodium Chloride 9% irrigation solution.

The warmed solutions lacked a date when placed in the warmer and/or when to remove from use.

Administrative staff C interviewed on 8/1/12 at 7:55am acknowledged the warmed solutions lacked a date when placed in the warmer and/or when to remove from use. Staff B could not assure the safety of the fluids.

The Critical Access Hospital (CAH) reported ten patients. Based on observation, staff interview and document review the CAH failed to develop and implement a system for identifying and controlling infections of patients and personnel.

Findings include:

- Staff I and J, observed on 7/30/12 at 1:10pm revealed the staff cleaning a discharged patient's room. Staff I and J removed their protective gloves five times without performing hand hygiene before applying another pair of protective gloves.

Staff A, interviewed on 7/31/12 at 2:00pm confirmed staff must perform hand hygiene after removing protective gloves.

The CAH's policy, reviewed on 8/1/12 at 3:25pm, confirmed hand hygiene is to be preformed "before and after the use of gloves".





25604

- The manufacturer's information for "Oxivir TB" germicidal cleaner reviewed on 8/1/11 at 3:25pm directed for disinfection "...All surfaces must remain wet 1 minute. Use a 5 minute contact time for TB and a 10 minute contact time for fungi..."

- Nursing staff L observed on 7/31/12 at 10:55am entered patient #31's room to obtain a glucometer (a machine used to test a patient's blood sugar level) test. Staff L performed the glucometer test using appropriate infection control technique. Staff L left patient #31's room and cleaned the glucometer with "Oxivir TB" wipes. The glucometer remained wet less than one minute and not the required ten minutes for total disinfection.

Staff L, interviewed on 7/31/12 at 11:12am, acknowledged the surface of the glucometer failed to remain wet for the required ten minutes for total disinfection.

- Nursing staff M observed on 8/1/12 at 10:55am performed a glucometer test on patient #34. Staff M performed the glucometer test using appropriate infection control technique. Staff N left patient #34's room and cleaned the glucometer with "Oxivir TB" wipes. The glucometer remained wet less than two minute not the required ten minutes for total disinfection.

Staff M and staff N, interviewed on 8/1/12 at 8:41am, acknowledged the surface of the glucometer failed to remain wet for the required ten minutes for total disinfection.

- Staff E, staff F and staff G on 8/1/12 between 10:08am to 10:55am cleaned operating room #1 of the surgical suite. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation for total disinfection. For example:

Staff G, staff H and staff I using "Oxivir TB" germicidal cleaner cleaned the patient bed and base, two linen stands, anesthetic machine, metal back-up table, and two arm boards. The surfaces remained wet between two to seven minutes. The surfaces failed to remain wet for the required 10 minutes for total disinfection.

Staff G, staff H, and staff I interviewed on 2/21/12 at 10:30am acknowledged the surfaces failed to remain wet the required 10 minutes for total disinfection.

- Medical staff Rules and Regulations require providers to complete the clinical records within ten days or be reprimanded.

- Staff J, interviewed on 7/31/12 at 4:30pm acknowledged the CAH policies and medical staff bylaws direct providers to complete the clinical records for each discharged patient within three days of the discharge date. Staff J acknowledged, on 8/1/12 at 5:30pm, the clinical records for 23% of the patients discharged in the last six months remained incomplete.


25604

The Critical Access Hospital (CAH) reported a census of ten patients. Based on clinical record review, policy review and staff interview the CAH failed to assure medical staff date and/or time all authenticated (signed) entries in the medical record for 16 of 34 clinical records reviewed (patient #'s 11, 12, 13, 14, 15, 16, 21, 22, 23, 25, 26, 28, 29, 31, 32, and 34).

Findings include:

- The CAH's policy "Deficiency List for Acute Care Charts" reviewed on 7/31/12 at 3:00pm directed "...Physician's signature and /or Mid Level Practitioner signature following each order, including date and time of signature..."

- Patient #23's clinical record reviewed on 7/30/12 at 11:30am revealed an admission on 7/18/12 with a diagnosis of Abdominal Pain. Patient #23's clinical record revealed between 7/18/12 to 7/30/12, six telephone/verbal orders lacked a time when authenticated by the provider.

- Patient #26's clinical record reviewed on 7/31/12 at 9:20am revealed an admission on 7/24/12 with a diagnosis of nausea. Patient #26's clinical record revealed between 7/24/12 to 7/31/12, one written orders and five telephone/verbal orders lacked a date and/or time when authenticated by the provider. Patient #23's clinical record revealed a Pre-anesthesia order and a Post-anesthesia order without the date and time when written.

- Patient #28's clinical record reviewed on 7/31/12 at 3:05pm revealed an admission on 5/31/12 and discharged on 6/2/12 for a surgical procedure. Patient #28's clinical record revealed between 5/31/12 to 6/2/12, three written orders lacked a time when authenticated by the provider. Patient #28's clinical record revealed a Pre-anesthesia order and a Post-anesthesia order without the time when written.

Staff D, interviewed on 7/31/12 at 2:00pm acknowledged the CAH failed to assure medical staff dated and timed all entries in the medical record.

This deficient practice also affected patient #'s 11, 12, 13, 14, 15, 16, 21, 22, 25, 29, 31, 32, and 34.