HospitalInspections.org

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Based on review of the hospitals policies and procedures, staff interviews, and review of the hospital's emergency services, the Critical Access Hospital (CAH) failed meet the Conditions of Participation for Emergency services. Failure to provide emergency care necessary to meet the needs of patients in the emergency department places patients at risk of harm and/or death related to lack of treatment or delays in treatment.

Due to the cumulative effect of deficiencies detailed under the Condition of Participation at 42 CFR 485.618 Emergency Services, the administration was notified on 9/16/15 at 4:35 pm that an immediate jeopardy was identified.

Specifically the immediate jeopardy identified the facility failed to ensure:

1. staff had the education and competency for emergency care across the life span;

2. implementation of policies, education and competency to staff for the use of emergency equipment;

3. safe storage of blood products; and

4. surveillance of infection control practices for the use of semi-critical items.

The facility implemented a plan to abate the immediacy on 9/17/15 at 3:30 am.

Refer to additional Citations 202-205 & 278

Record review from 9/7-11/15 revealed the facility had not defined the scope of emergency services the CAH could provide.

Record review revealed the facility failed to ensure the Emergency Department policies had been reviewed and updated annually by the medical director and or quality assurance committee.

Record review and interview revealed the facility failed to development a policy and ensure the skills and education competency of nursing staff for the use of emergency equipment; specifically the use of the ventilators and the cleaning of the laryngoscope blades and the glydiscope used for intubation.

Record review and interview revealed the nursing staff had not had emergency and trauma care specific for the pediatric population.

Record review and interview revealed the facility failed to ensure the integrity of emergency blood products were not compromised by out of range temperature during off hours by laboratory services.

Record review and interview revealed the facility failed to ensure the competency and documentation per policy for a patient who received conscious sedation. Refer to citation C294.

During observations, staff interviews and record review revealed the facility failed to ensure the integrity of sterile supplies and failed to identify or remove compromised sterile packages from service.

During multiple interviews from 9/7-11/15 and 9/15-18/15 the Administrator and/or the newly hired Director of Nurses confirmed the above findings.


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Based on observation and interview the facility failed to ensure emergency medications and sharps were secured at all times. Failure to secure medications and sharps had the potential to compromise the medications for availability and or contamination. Findings:

Observations from 9/7-11/15 and again from 9/15-18/15 revealed the code cart with emergency medications, in room 2, had a lock on the cart that did not secure the contents.

Observations on 9/7/15 from 12:00 pm - 1:00 pm and again on 9/17/15 at 3:00 pm revealed the sharps in ED rooms 1 and 2 were unsecured in cupboards and drawers.

During an interview on 9/18/15 at 9:40 am RN #2 confirmed the tag lock on the code cart was not securing the contents.

During an interview on 9/10/15 the DON confirmed sharps and medications in the ED should be stored securely.



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Based on observation and interview the facility failed to ensure semi-critical emergency equipment was sterilized after use. Failure to not clean equipment appropriately placed all patients at risk for toxin ingestion, infection, and or infectious disease. Findings:

Observations on 9/8/15 at 12:25 pm revealed a cardiac arrest was in progress in the ED and the patient had been intubated by the MD using a laryngoscope blade.

Observation in the ED on 9/8/15 at 6:45 pm revealed a laryngoscope blade lying on top of the procedure cart in the ED.

During interviews on 9/8/15 at 6:45 pm Staff's responsible for sterilization and the nursing staff on duty was asked how they would clean the laryngoscope blade if it had been used. Each of them stated they did not know. The person who does sterilization stated it could not be autoclaved.

During an interview on 9/9/15 at 9:30 am Staff #1 stated the laryngoscope was sprayed with Virex (germicidal disinfectant) and then wiped down with a germicidal cloth (Super Sani-Cloth) and placed back in service. Both the Virex and the germicidal cloths are harmful to skin, eyes, and mucous membranes.

During an interview on 9/17/15 at 9:55 am RN #2 stated she had been told the laryngoscopes were to be cleaned with Virex and wiped with a germicidal wipe.

No policy available for the cleaning of semi-critical instruments.


Refer also to citation 278

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Based on observation and interview the facility failed to ensure the integrity of blood products for use in an emergency. Failure to provide 24/7 monitoring of blood product's temperature at all times, placed all patients who may require a blood transfusing at risk for death. Findings:


During an interview on 9/8/15 at 10:40 am the Lab Director stated the alarm on the refridgerator that was used for emergency blood storage did not have an audible temperature alarm that could be heard after lab hours. He stated the alarm could only be heard if a person was in the laboratory.

In addition, stated the inability for anyone to hear the blood bank alarm if not directly in the lab had been identified on the 5/22/15 mock survey.

Record review from 9/7-11/15 of the "Blood Bank Refrigerator Alarm Verification" policy dated 8/22/14, revealed "Continuous monitoring... and 24 hour per day audible alarm... evaluate the nursing staff response to the blood bank alarm..."

Record review of the "Blood Bank Alarm" policy, revision date 8/22/14, revealed "...whenever the blood bank alarm is activated, nursing staff will notify the laboratory and maintenance person immediately".



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Based on record review and interview the facility failed to ensure: 1) essential equipment and life safety protection systems had been maintained and serviced and 2) appointed staff were reporting compliance to leadership. These failed practices had the potential for unmaintained equipment and protections systems to fail or go unnoticed. This placed all occupants of the building at risk for loss of services and/or an undesirable emergency environment. Findings:

Refer to the LSC 2567 report for the LSC deficiencies.

Record review from 9/7-11/15 of the Quality Management Committee (QMC) meeting minutes revealed no documentation of reports, inspections, or concerns reported to the QMC for 2014. In addition, review of the QMC minutes for 2015 revealed the first meeting was held on 5/29/15, one week after the facility had a mock compliance survey.

Record review from 9/7-11/15 of the Governing Body minutes, provided by the facility, dated 1/23/14; 4/2/14; 7/2/14; 1/7/15; and 4/15/15 revealed no documentation of compliance with LSC inspections on essential equipment.

Record review from 9/7-11/15 of the "Quality Improvement Administrative Policy" dated 5/27/10, revealed "...Each service area will be responsible for developing a quality improvement plan specific to their area and will report to the Administration on a scheduled quarterly basis..."

During an interview on 9/10/15 at 4:30 pm the Administrator stated the Maintenance Director was new to his position and was not able to find the documentation. In addition, when asked if he was requesting, receiving or reviewing documentation of compliance records with LSC inspections he stated he relied on the Director of that department to ensure compliance.

During an interview on 9/16/15 at 2:30 pm the Director of Facility Services, who is also the Chief Financial Officer, stated she had been appointed the Director over Facility Services in February. When asked if she had inquired, reviewed, or reported any compliance data to the Governing Body, Administrator, or QMC she stated she had not.





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Based on observations and interview the facility failed to: 1) ensure preventative maintenance was completed on all patient care equipment; 2) provide a list of equipment with the preventative maintenance schedule; and 3) provide a current contract for biomedical services. This failed practice placed patients at risk for inadequate care as a result of insufficient oversight of medical equipment. Findings:

Observations of preventative maintenance (PM) stickers on equipment from 9/7-11/15 revealed the following expired preventative maintenance items:

· 3 respiratory nebulizers with a "last PM" date of 3/28/04, 3/27/01, and 5/28/02;

· 1 respiratory nebulizer with no PM sticker at all;

· 1 wound vacuum with a "last PM" date of 6/4/13;

· 1 glucometer, used by the critical access hospital and the emergency department, had no preventative maintenance date and medical employees were unable to locate the manual or policy for its use; and

· Two gravity sterilizers in use had no documentation of the last preventative maintenance.

During an interview on 9/11/15 the Administrator was asked to provide a copy of the current biomedical contract and an itemized list of equipment for preventative maintenance.

No documentation was provided by the survey exit.


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Based on record review and interview the facility failed to complete and maintain documentation of fire drills and ensure the completion of one drill quarterly per shift. This failed practice placed all residents, staff and visitors at risk for delay in response during a fire emergency due to inadequate staff training. Findings:

Record review on 9/10/15 revealed no documentation of proper fire drills conducted during the review period of 2014-2015.

During an interview on 9/10/15 the Maintenance Supervisor confirmed there was no documentation of fire drill that fulfilled the regulatory requirement.



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Based on interview the facility failed to ensure an agreement with a community entity for the provisions of fuel and or water in the event of a loss of those services. This placed all occupants of the facility at risk for loss of emergency electrical services and water supply in the event of emergency. Findings:

During an interview on 9/11/15 at 9:00 am the Administrator stated the facility had no official agreement for water or fuel with the city.



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Based on record review and interview the facility failed to ensure corridor doors were not wedged and that annual and quarterly inspections on essential mechanical equipment had been completed. This failed practice placed the all residents, staff and visitors at risk of exposure to a smoke and fire environment.

Refer to LSC 2567 report.


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Based on interview the facility failed to provide quarterly sprinkler inspections; documentation of the kitchen hood suppression system inspections and the cleaning of the exhaust system at appropriate intervals; documentation and completion of appropriate and timely inspections. Findings:

Refer to LSC 2567



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Based on review of policies and procedures, meeting minutes, and staff interviews the Critical Access Hospital (CAH) failed meet the Conditions of Participation for Organizational Structure. Failure to oversee and evaluate the CAH operations placed all patients at risk for injury due to lack of policy, procedures, surveillance, reporting, and skill of staff. Refer to C 241.




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Based on interview and record review the Governing Body/CEO failed to ensure the operations of the Critical Access Hospital were monitored, evaluated, and reported on a continual basis for the safe operation of services and quality of care for the patients it serves. Findings:

Based on record review of the Quality Improvement Committee and the Health Service Board meeting minutes, dated from the year 2014 - 2015 and the 2014 year-end Operating Report provided the to the Health Service Board on 3/2015 revealed no documentation of ongoing evaluation of the scope of CAH services.

Based on record review the facility failed to ensure the medical staff by-laws had been review and updated annually.

The medical staff bylaws that are signed the by 4 medical staff providers state "active staff shall perform and be responsible for... medical record review.... Through the utilization review committee..."

During an interview on 9/16/15 the CEO stated the facility did not have a utilization review committee which was further confirmed by the CFO.

Review of the "Utilization Review Plan, draft," dated 10/5/04 revealed "Community medical center will maintain a UR program ... and be reviewed and evaluated at least annually and will report findings to the Quality Improvement Administrative Committee."

During interviews from 9/7-11/15 with the DON, Medical Director and CEO it was determined the facility did not have an infection control plan or committee.

In addition, the Quality Improvement or QMI committee had not meet for the year 2015 until after a mock survey had been completed on 5/22/15. From that mock survey only 3 actions plans were developed and provided to the surveyor.


During an interview on 5/10/15 the HR Director, also responsible for credentialing was asked for the policy for credentialing. She stated the facility had no policy that defined the credentialing process.


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Based on review of the hospitals policies and procedures, staff interviews, and review of the hospital's emergency services, the Critical Access Hospital (CAH) failed meet the Conditions of Participation for Provision of Services. Failure to identify and evaluate the CAH services prevents the CAH from meeting the needs of patients and places patients at risk of harm related to lack of treatment or delays in treatment.

Due to the cumulative effect of deficiencies detailed under the Condition of Participation at 42 CFR 485.635(a) (3) for infection prevention the administration was notified on 9/16/15 at 4:35 pm that an immediate jeopardy was identified.

Refer to citations C-271-1002




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Based on record review and interview the facility failed to ensure the nursing staff had been provided the necessary education, training, and competency to assist the medical provider with conscious sedation. Findings:


Record review on 9/10/15 revealed no nursing staff had documentation of conscious sedation education that had been approved by the Alaska State Board of Nursing.


During an interview on 9/10/15 at 2:35 pm the DON stated she did not believe the RN's had received any special trained for conscious sedation.




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Based on record review and interview the facility failed to review and revise policies as needed, and on an annual basis. Lack of policy and procedure oversight, which facilitates the hospital's functionality, placed all current and future patients at risk of inadequate care and services. Findings:

Record review from 9/7-11/15 and 9/15-18/15 of the "QMC" (Quality Improvement) minutes, dated for the year 2014 - 9/18/15, revealed no documentation of any policy approval.

Record review of the policy "Annual Policy and Procedure Review and Renewal draft," no date, revealed "Each Department Manager and Committee Chair is responsible for reviewing and renewing their respective documents on an annual basis."

During an interview on 9/8/15 at 9:45 am the QMC Chairman stated no polices had been approved by the QMC committee for the year 2014 - 9/8/15.

During an interview on 9/10/15 at 2:00 pm the Administrator stated the QMC committee had not been meeting regularly and he was not sure if any policies had been approved by the committee this year.



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Based on record review and interview the facility failed to ensure a policy had been written defining the CAH services to include contracted services for any continued patient care and services. Findings:


During an interview on 9/9/15 10:30 am the Administrator confirmed the facility did not have a policy defining what services were provided on site at the CAH and which patient care services were contracted out.



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Based on record review and interview the facility failed to ensure a policy had been written defining the CAH Emergency services to include any contracted services for continued patient care and services. Findings:

During an interview on 9/9/15 the Administrator confirmed the facility did not have a policy defining the emergency services provided on-site or which patient care services were contracted out.



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Based on interview the facility failed to ensure periodical review of patients who were transfered to another facility for a higher level of care. Findings:

During an interview on 9/10/15 at 10:25 am the CEO stated he was not able to locate any transfer audit results and stated that was the responsiblity of the DON.



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Based on observation, interview and record review the facility failed to ensure: 1) medications, sharps, and lab supplies were secured; 2) expired medications were removed and discarded; 3) refrigerator temperatures were recorded twice daily; and 4) the disposal of medications were not put in the public sewer system. Findings:



Unsecured sharps, unsecured and expired medications:

Observations on 9/7/15 from 12:00 to 4:00 pm, in emergency department (ED) rooms 1 & 2 revealed unsecured sharps and syringes with needles; hemocult testing bottles; multiple expired lab tubes and unsecured medications in the code cart.

Further observations on 9/17/15 at 3:00 pm revealed unsecured medications in the code cart and sharps in ED room 2.

Observations on 9/7/15 from 12:00 to 4:00 pm, in the obstetrics (OB) room revealed the following expired medications:

· 1 ampule of epinephrine 1:1000 mg expired on 6/15;
· 1 Ca Gluconate 10% expired on 4/15;
· 1 vial narcan expired on 8/15;
· 1 1:10,000 mg epinephrine syringe expired on 6/15;
· 1 2 fl oz. 6 pack of Enfamil formula expired on 3/1/15;
· 1 2 fl oz. 6 pack of Enfamil 50% glucose expired on 8/1/15;
· Multiple lab tubes had expired in 4/15 and 8/15.

Further observations in the pantry near the pharmacy revealed 3 cans of Ensure expired on 6/1/15 and 7 cans that expired on 8/1/15.


The medication area inspection report completed by the Pharmacist for 7/24/15 revealed a line item that stated to "verify completion of daily refrigerator temperature log twice daily..." The facility had no documentation that any of the refrigerators had a temperature recorded twice daily, to include the vaccine refrigerator.


During an interview on 9/8/15 at 1:55 am RN #1 stated all refrigerator temperatures were recorded once daily. In addition, confirmed a vial of the MMR (Measles, mumps, rubella) vaccine was in the refridgerator currently and that the influenza vaccine would be arriving any day.

The facility had no policy on recording the vaccine refrigerator temperature twice daily.


Record review of the 4/8/15 quarterly pharmacy report revealed, "long term narcotics will be wasted in the hopper in the medication room..."

During an interview on 9/10/15 at 2:00 pm the Pharmacy technician stated medications were currently being disposed of in the hopper.

Multiple requests from 9/7-11/15 and again from 9/15-18/15 were made to the Administrator for the medication event investigations. No investigation reports were provided.




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Based on interview, record review and interviews the facility failed to ensure: 1) the effective development and implementation of an infection control plan and committee; 2) facility staff providing sterilization of surgical equipment and high level disinfecting of semi-critical equipment had training and oversite; and 3) development of infection prevention and equipment sterilization policies based on best practice standards.

This failed practice placed patients utilizing facility services at immediate risk for harm or death from infections. Facility administrative staff was notified of the immediate jeopardy on 9/16/15 at 4:20 pm.

The facility provided a plan that abated the immediacy on 9/17/15 at 3:33 pm.

Infection Control Committee

Record review from 9/7-11/15 revealed no documentation of infection prevention reporting to the Quality Committee.

Record review revealed no infection control plan, antibiotic stewardship process, committee meeting notes, current policies or surveillance for sterilization, or any infection prevention practices .

During an interview on 9/8/15 at 1:30 pm the Director of Nursing (DON) stated there was no policy that defined the Infection Control Plan. In addition, the DON stated she was unable to locate any meeting minutes for an infection control committee, or any surveillance policies.

During an interview on 9/9/15 at 3:00 pm the Administrator stated he could not recall when the last infection control meeting was due to the turnover in staff this past year.

During an interview on 9/9/15 the Chairman of the Quality Committee states he did not recall receiving any reports from the infection control committee in the past year.

Contaminated Instruments and Supplies

Observation on 9/7/15 from 12:00 - 1:00 pm in the Emergency Department rooms 1 & 2 revealed multiple rust colored instruments packaged in sterile pouches. In addition, dried water stains were present on the packages of sterile supplies and the instruments in sterile pouches were clamped shut.

Observations on 9/7/15 from 1:00-2:30 pm in the central storage area where additional sterile supplies were stored revealed multiple sterile packs and pouches with rust colored instruments, instruments that appeared to be in the locked position, and water damaged packaging.

During an interview on 9/8/15 between 7:30 pm and 8:30 pm, when asked if the items in the pouches had been sterilized and were available for use, Staff #1 stated, they were OK to use because they were dried spots and the packages had not been torn. During the interview Staff #1 confirmed she was responsible for cleaning and sterilization of the instruments.

During an interview on 9/9/15 at 4:30 pm Staff #2 stated the sterile packages with water damage were OK to use as they were dry and that if they had any rusty instruments they would return them to materials management for replacement. Water damaged sterile packaging should be removed from service, repackaged, and re-sterilized. In addition, rusty instruments cannot be sterilized due to the cavitation the rust caused on the stainless steel. Staff #2 stated her job duties included sterilization and cleaning of the instruments.

In addition, Staff #2 was shown several pouches with instruments that were clamped shut and asked if that was how they were to be sterilized and said the instruments should not be clamped closed in the packages. After the interview, Staff #2 did not remove the compromised packages from service.

Record review of the policy "Preparation & Sterilization of supplies and sets" dated 10/6/08, revealed practices that were not followed and incorrect practices and should be rewritten to meet the best practice standards.

Record review of the employee files for both Staff #'s 1 & 2 revealed no education on sterilization.

Spore Testing

Observations on 9/8/15 of the sterile processing room revealed the Steris Autoclave [sterilizer] had preventative maintenance sticker that expired on 5/15. No preventative maintenance sticker was present on the Quant lM16 desktop sterilizer.

Record review of the instruction sheet "Sterilizing Room" posting near the Steris Autoclave dated 7/04 revealed:

"2. The double door [Steris Autoclave] is to have a spore test run every Monday or when a full load is run;

3. Run a spore test on the table top sterilizer 1st week of every month..."

During an interview on 9/8/15 at 7:35 pm Staff #1 stated she was not aware of who read or documented the spore tests that were done. She thought lab staff was responsible. In addition, confirmed she was not aware of any documentation related to spore testing. She stated she was trained to run a spore test when running the autoclave and then took the ampule to the lab and placed it in the warmer and had never read one.

During an interview on 9/8/15 at 5:45 pm, Laboratory Staff #1 stated the lab had nothing to do with the reading of the spore testing for the autoclaves.

Record review of the "Spore Testing" log revealed no entries.

Record review of the policy "Biological (Spore Test) for the Steam Autoclave", dated 10/6/08, revealed "Retrieve the indicators [spore tests] ...sent to lab for culturing ...the results are kept ...by the laboratory department ...if a spore test comes back abnormal Lab will contact the Infection Control Nurse or designee ..."

Further review of the policy revealed the facility does not have best practice standards outlined in their policy for spore testing.

Sterilization

Observations of multiple sterile pouches of instruments, bowls, and wrapped sets, revealed no internal indicators were present.

No policy was available that addressed the use of chemical indicators.

Observation of a note on the wall by the autoclave revealed the staff was to go downstairs, turn the boiler on, and let it run for 30-35 minutes before starting the autoclave.

During an interview on 9/8/15 at 7:45 pm Staff #1 stated she would turn the boiler on, then go back upstairs, and turn the autoclave on. She stated you did not have to wait for 30 minutes before running a sterilization load in the autoclave.

During an interview on 9/10/15 at 10:35 am the Maintenance Supervisor stated the staff should wait 1 hour after turning the boiler on to run the autoclave.

Record review of several rolls of the autoclave recordings revealed no staff had validated autoclave sterilization parameters had been met before placing items in service.

No policy was available for the process of turning on the boiler that identified a consistent time to wait before starting the autoclave or how and when to validate sterilization.

Bowie Dick (Air testing) of the Autoclave

During an interview on 9/9/15 at 4:45 pm Staff #2 stated prior to using the autoclave she would run a Bowie dick test (this measures the air removal in a gravity sterilizer in a pre-vac mode). However the autoclave tape revealed the facility only ran gravity sterilization loads and a Bowie dick test is not needed and provided no value in testing the sterilization for the types of loads being ran.


Water Filtration (DI) System

Observations from 9/7-11/15 revealed the facility had DI system used for several sterilization processes.

Record review of the "Sterilizing Room" task list dated 7/04 revealed a DI water culture was to be taken monthly and sent to the lab.

During an interview on 9/8/15 at 7:35 pm Staff #1 stated she did not know who changed the filters on the table top DI or the facility DI.

Record review of the water cultures kept in a notebook in the lab revealed only 3 water cultures had been done for the year 2015.

During an interview on 9/8/15 at 5:45pm Lab Staff #1 stated he placed the water culture results in the blue notebook located in the lab. In addition, he stated that he did not know who reviewed the results he was just told to place them in the blue notebook in the lab. Lab Staff #1 also stated that he did not report the results to anyone when they returned and was not responsible for collecting the sample.

Record review on 9/7/15 of the DI water culture reports revealed the last water culture had been completed on 3/25/15. In addition, the previous water culture report on the DI water was done on 12/12/14.

No policy was provided on the culturing of the DI water systems.

Cleaning of semi-critical instruments

Observations on 9/8/15 at 12:25 revealed a cardiac arrest was in progress in the Emergency Department (ED) and the patient had been intubated by the MD.

During an observation in the ED on 9/8/15 at 6:45 pm revealed a laryngoscope handle and blade lying on top of the procedure cart in the ED.

During interviews on 9/8/15 at 6:45 pm when asked how they had cleaned the laryngoscope blade after use Staff #'s 1 & 2 stated they didn't know.

During an interview on 9/9/15 at 9:30 am Staff #1 stated the laryngoscope was sprayed with Virex (germicidal disinfectant) and then wiped down with a germicidal cloth (Super Sani-Cloth) and placed back in service as clean and ready for use. Both the Virex and the germicidal cloths are harmful to skin, eyes, and mucous membranes.

During an interview on 9/17/15 at 10:40 am, RN #2 stated laryngoscopes were cleaned with Virex and wiped with a germicidal wipe.

Review of the Material Safety Data Sheet (MSDS) for Virex revealed "Principle routes of exposure: Eye contact. Skin contact. Inhalation. Eye contact: Corrosive. Causes permanent eye damage, including blindness. Skin contact: Corrosive. Causes permanent damage. Inhalation: May cause irritation and corrosive effects to nose, throat and respiratory tract. Ingestion: May be irritating to mouth, throat and stomach."

Review of the MSDS for Super Sani-Cloths revealed: PRECAUTIONARY STATEMENTS: Hazards to humans and domestic animals. Causes irreversible eye damage. Do not get in eyes or on clothing. Avoid contact with skin. Wash thoroughly with soap and water after handling and before eating, drinking, and chewing gum, using tobacco or using restroom. Remove and wash contaminated clothing before reuse. Inhalation Not a normal route of exposure. Chronic effects Prolonged or repeated exposure can cause drying, defatting and dermatitis. OSHA Regulatory Status This product is a 'Hazardous Chemical' as defined by the OSHA Hazard Communication."


No policy was available for the cleaning of semi-critical instruments.


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Based on record review and interview the facility failed to ensure the nursing staff had the knowledge, skills, competency and policies, to provide emergency and trauma care across the age spectrum. Failure to have knowledgeable, trained, competent nursing staff prevented all patients of all ages from receiving the best and safest care during an emergency. Findings:

Record review from 9/7-11/15 of the all nursing staff's education files currently working both the acute care and emergency department revealed no adult or pediatric trauma education or certification.

During an interview on 9/10/15 the Director of Nurses and the Medical Director were not aware the only certification nursing staff had was ACLS and BLS.

In addition refer to C 200 - 205


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Based on record review and interview the facility's governing body and CEO failed to ensure oversite of contracted services. Failure to ensure a list of contracts was maintained current prevented the CAH from ensuring care and services were provided to comply with the conditions of participation. Findings:

Record review from 9/7-11/15 of the contracted services list revealed the following contracted services had expired:

· Pharmacy contract expired on 7/15/15.
· Quest Diagnostics expired 7/15/13;
· Providence Medical Center transfer agreement expired on 5/1/2007;
· Advanced Diagnostics Inc expired on 6/6/14;
· Landauer Inc. expired on 11/20/14;
· Universal Solutions expired on 1/29/14;
· Delta Health Care Providers expired on 11/3/13;
· Medical Solutions expired on 5/28/15;
· Wilderness Medical Staffing expired on 12/2/14;
· Locum Leaders expired on 1/15/14;
· ANM Helathcare INC expired on 7/14/15;
· RAPC expired 3/31/10.

Review of the Pharmacist contract that expired on 7/14/15 revealed "Consultant shall provide the following Administrative services:

· ...Compliance review for all Federal, State and Critical Access Hospital ... conditions for participation;
· ...Comprehensive Pharmacy oversight ... as determined by ... policies and procedures;
· ...participation P & T quarterly meetings;
· ...written quarterly status report on the pharmacy and consultants recommendations ..."


Further review of the Pharmacist reports from 1/1/14 - 9/18/15 revealed a single surveillance that had occurred on 7/24/15.



Record review of the Pharmacy policy list provided on 9/8/15 revealed the pharmacy policies had last been approved in 2007, 2008, and 2010.



Records were requested multiple times, from the CEO, to provide an evaluation of the contracted services and no documentation was provided by the survey exit.



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Based on record review and interview the facility failed to ensure: 1) 3 of 3 RNs, and 1 of 3 CNA's records reviewed had completed a job specific orientation; 2) 8 of 10 staff due for an annual or 90 day evaluation had no record on file; 3) documentation of medication competency for nurses; 4) documentation of conscious sedation competency.

Orientation and evaluations:

· Record review on 7/10/15 of RN #s 1, 9 and 10 revealed no job specific orientation had been completed.
· Record review CNA #2 revealed no job specific orientated had been completed.
· Record review of RN #s 1, 2, 4, & 5 had no annual evaluation completed.
· Record review of CNA #s 1, 2, & 3 had no annual evaluations completed.

Review of the policy "Performance Evaluations" no date, revealed "Proper documentation of each employee's job performance will be maintained and recorded..., 90 day performance evaluation for new employees..., and annual performance evaluations for each employee..."

During an interview on 9/10/15 the HR Director confirmed the missing job specific orientations and confirmed no annual evaluations were present for any staff.

Medication competency

Record review of the P & T minutes dated 7/16/14, revealed "Adverse drug events quarterly report was discussed; however there was no report available for this quarter."


Record review of the P & T minutes dated 11/13/14, revealed "four reports within the last 2 quarters...". No supporting documentation of the medication events or the investigation.

Record review of the P & T minutes dated 7/20/15, revealed "Medication error report..., 9 reports since May....". No supporting documentation of the medication events or the investigation."

During an interview on 9/10/15 at 3:10 pm the Pharmacist confirmed, to his knowledge no medication administration testing had been completed for nursing staff. In addition, stated he did not have copies of the medication events or the investigation.

Conscious sedation

Record review on 9/17/15 revealed Patient #18 had received conscious sedation on 8/9/15 for a shoulder reduction. No consent was present in the medical record and there was no documentation of RN competency for conscious sedation and no documentation of ongoing vital signs.

During an interview on 9/16/15 at 11:00 am RN #2 stated she had not had any additional education for conscious sedation. In addition, stated she did not recall needing a consent for conscious sedation or that any additional nursing care or assessments would be necessary during the administration of a benzodiazepine and narcotic for the purpose of conscious sedation.

Record review of the "Conscious Sedation" policy dated 3/19/08 revealed policy was still in "draft" and had no documentation of approval.



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Based on record review the facility failed to ensure complete and accurate documentation in the medical record. Findings:

Closed record review of the transfer agreement dated, 9/2/15 for Patient #1 revealed the transfer agreement had no documentation of how the patient was to be transferred; who the patient was discharged to; date; time; or who report was called to.

Closed record review for Patient #1 revealed the physician ordered for the patient to follow up with a specific physician in one week. Further review of the discharge instructions provided to the patient did not reveal documentation of a follow up.
Closed record review for Patient #2 revealed the transfer form dated 5/16/15 was incomplete of all nursing documentation to include: who report was given to; when and how and at what time the patient was transferred.

Closed record review for Patient #3 admitted to swing bed status on 8/14/15 revealed no documentation of a care plan.

Review of the policy list provided revealed no policy on swing bed admissions.


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Based on record review and interview the CEO and the Governing Body failed to meet the Conditions of Participation: Periodic Evaluation and Quality Assurance Review. As a result, the CAH did not have an ongoing data-driven Quality Assurance program that collected and analyzed data on various aspects of quality of care and used the data to assess quality and implement performance improvement projects. This limits the CAH's ability to evaluate their systems and process.

As a result of not having a Quality Assurance Committee the CAH was not in compliance with citations C330 - 343.


Record review from 9/7-11/15 of the "Organizational Performance Plan" dated 12/06/15 revealed:


"The committee is responsible for providing a systematic mechanism for reviewing patient related processes on continual bases for the purpose to monitor analyze and improve patient outcome. QMC provides oversight to the sub-committees and assures the adherence to each committee's requirements...:

representatives from each department and patient care area...;

will meet on a quarterly basis...;

will provide a quarterly report to the administrator concerning committee and subcommittee activities and any relevant findings...;


the sub committees are:

Fire/Safety/Disaster; Infection Control Committee; Management of Information Committee; Medical Staff; Pharmacy and Therapeutics Committee; Quality Improvement Committee; Utilization Review; Ethics...;

each committee is required to establish a statement of purpose that meets the approval of the QMC...;

they [QMC] have the responsibility to evaluate the effectiveness of the Organizational Performance Plan as a whole... and provide such reports to the Health Services Board."


Record of the "Quality Improvement Administrative Policy" dated 5/27/10 revealed:


"Cordova Community Medical Center will maintain a Quality Improvement (QI) program to ensure the delivery of quality health care and service....;


Objectives:

...to maintain and improve patient care... to evaluate productivity and proficiency of professional and nonprofessional staff; to identify and reduce areas of high risk in care and service areas; to meet the standards established by federal, state and local regulations...; provide a method of assessing the quality and appropriateness of patient care...;


Responsibilities:

...develop and approve the facility's overall quality improvement plan; approve each service areas plan; coordinate interdepartmental monitoring and evaluations...; provide direction... determine specific dates each service area will submit reports; evaluate written reports; ensure that corrective action is implemented and effective; monitor follow up; annual review and approve each year's annual appraisal and monitoring calendar..."


During multiple interviews from 9/7-11/15 the CEO stated the facility did not have a policy that defined the CAH services or Emergency Services. As a result no annual or periodic evaluation of services had been completed or documented.



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Base on record review the facility failed provide documentation of an annual review of all CAH services to include the volume of services.


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Base on record review the facility failed provide documentation of clinic record audits both open and closed records.



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Based on record review the facility failed to provide documentation of annual review or revision of all CAH policies.




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Based on record review the facility failed to provide documentation of and evaluation of the annual review or revision of CAH services and policies.




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Based on record review the facility failed to provide documentation of an ongoing data driven Quality Committee.




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Based on record review the facility failed to ensure the person appointed by the governing body had effectively documented evaluations of patient care and services the CAH provides.




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Based on interview and record review the facility failed to ensure the implementation of an infection control plan or infection control committee to monitor infections or antibiotic usage. Refer also to C-278


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Based on record review the facility failed to ensure a documentation of a current contract with a QIO, or evaluations of physician services prior to the mock survey on 5/22/15.




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Based on interview and record review the Critical Access Hospital (CAH) failed to meet the Conditions of Participation for Organ,Tissue, and Eye Procurement by failing to ensure a contract was in place, training had occurred, and policy and procedures had been developed and implemented for the procurement of organs, tissues and eyes after or upon known imminent death. This failure denies families the right to be made aware of the option for organ or tissue donation.
Findings:

Record review on 9/9/15 at 9:00 am of Patient #1 revealed the patient was pronounced deceased at 12:30 pm by the physician. In addition the record revealed no documentation the facility had notified an Organ Procurement Organization (OPO) for organ, eye, bone, or tissue procurement.

During an interview on 9/10/15 at 9:30 am RN #1 was asked for the facility policy and or procedures for organ procurement and after looking, stated she could not find a policy.

During an interview on 9/10/15 at 10:45 am the Administrator stated there was no contract or agreement with an OPO. In addition he stated he was not aware of any policy or procedures.

Record review from 9/7-11/15 of the education files for the RN's revealed no documentation of OPO training.




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Based on record review the facility failed to have policies and procedures in place regarding inpatient and outpatient visitation rights, which included any restrictions or limitations, and how the hospital staff would be trained to appropriately deal with the visitation rights of the patient. This deficient practice created the potential for unnecessarily restricting visitation by staff not knowing what restrictions or limitations are clinically necessary. Findings:

Record review from 9/16-18/15 of the admission packet provided revealed no policy or procedure that addressed patient visitation rights to include any restrictions or limitations, and how the staff would be trained.



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Based on record review the facility failed to have written policies and procedures in place regarding inpatient and outpatient visitation rights that included: 1) informing each patient of his/her visitation rights, including any clinical restrictions; and 2) informing each patient of their right, subject to their consent, to have whomever they wish visit. Without these policies, patients and their visitors lacked information regarding any clinical restrictions that would contraindicate visits. Findings:

Review of the facility's policy "Acute Care Rights and Responsibilities," no date, revealed no policy or procedure which addressed patient visitation rights to include: 1) informing each patient of his/her visitation rights, including any clinical restrictions; and 2) informing each patient of their right, subject to their consent, to have whomever they wish visit.



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Based on record review the facility failed to have policies and procedures in place regarding visitation rights, which included any restriction or limitation in place and the reason for the restrictions. By not implementing these policies there is the potential for patients having unequal and inconsistent visiting rights. Findings:

Review of the facility's policy "Acute Care Rights and Responsibilities", no date, revealed no policy or procedure which addressed any restriction or limitation and the reason for the restrictions; specifically, addressing unequal and inconsistent visiting rights.



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