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Based on interview and review of telemedicine agreement, the facility failed to provide internal review of telemedicine practitioners and failed to send the distant-site providers such information for use in the periodic appraisal of the individual distant-site physician or practitioner. This practice had the potential to affect the services received by all patients receiving telemedicine services.

Finding Include:

Review of the "Professional Services Agreement" between the Critical Access Hospital and (Physician) as medical director for Hospital's psychiatric and behavioral health services, entered on October 30, 2017, provided by Chief Executive Officer (CEO) on 12/18/18 at 1:13 PM, showed the facility would "Exhibit A ...(g) Continually review the professional performance of all individuals who have clinical privileges or are approved to provide specified psychiatric and behavioral health services."

Review of the "Telehealth Provider LLC" agreement, entered on 11/24/2015, and amended on 07/31/2017, provided by the CEO on 12/19/18 at 2:55 PM, lacked evidence of verbiage for the facility to provide internal review of telemedicine practitioners, and to provide this information to the distant-site provider to be used for periodic review of practitioners.

During an interview on 12/18/18 at 1:07 PM, the Chief Executive Director (CEO) and the Director of Nursing (DON) provided a document titled "(Town) District Healthcare Business Associate Contract Review and Evaluation Form," last revised Dec 2017. The CEO and DON stated they had discussed use of this form in their corporate compliance meetings. However, the use of the form to provide feedback to the telemedicine provider agencies had not been implemented and was not a current performance improvement project in the Quality Assurance/Performance Improvement program.

During an interview on 12/18/19 at 1:55 PM, the CEO stated that the facility did not have a system in place to provide feedback information for the telemedicine providers.

Based on observation, document review and staff interview, the facility failed to make adequate provisions to ensure the safety and reliability of its equipment for operations and services when it failed to provide testing of the medical gas systems since 2014. This deficient practice could adversely affect any patient using or receiving medical gases from the bulk medical gas system. The facility has a capacity of 10 and census of 1 at the time of the survey.

Findings Include:

The Life Safety Code (LSC) Inspector observed on 01/02/19 that the medical gas system did not have an annual inspection.

The LSC Inspector's interview on 01/02/19, Staff M1 stated that there had been no inspection and testing of this piped oxygen system or master alarms since installation in 2014.

Additional information obtained from the LSC Inspector on 01/03/19, the facility usually did surgery one day a month, but currently had no surgeries scheduled. The facility does not do any emergency surgeries including obstetric patients. The facility scheduled an inspection of the medical gas system on 01/08/19.

Review of the following National Fire Protection Agency (NFPA) Standard revealed: Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Health care facilities with installed medical
gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 2012 NFPA 99, 5.1.14.2.1

Review of the following NFPA Standard revealed: Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.4

Review of the following NFPA Standard revealed: A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented. 2012 NFPA 99, 5.1.14.4.5

Based on observation, document review and staff interview the facility failed to make adequate provisions to ensure the safety and reliability of its equipment for operations and services when it failed to provide testing of the medical gas systems since 2014. This deficient practice could adversely affect any patient using or receiving medical gases from the bulk medical gas system. The facility has a capacity of 10 and census of 1 at the time of the survey.

Findings Include:

The Life Safety Code (LSC) Inspector observed on 01/02/19 that the medical gas system did not have an annual inspection.

The LSC Inspector's interview on 01/02/19, Staff M1 stated that there had been no inspection and testing of this piped oxygen system or master alarms since installation in 2014.

Additional information obtained from the LSC Inspector on 01/03/19, the facility usually did surgery one day a month, but currently had no surgeries scheduled. The facility does not do any emergency surgeries including obstetric patients. The facility scheduled an inspection of the medical gas system on 01/08/19.

Review of the following National Fire Protection Agency (NFPA) Standard revealed: Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 101, 19.3.2.4

Review of the following NFPA Standard revealed: Health care facilities with installed medical
gas, vacuum, WAGD, or medical support gas systems, or combinations thereof, shall develop and document periodic maintenance programs for these systems and their subcomponents as appropriate to the equipment installed. 2012 NFPA 99, 5.1.14.2.1

Review of the following NFPA Standard revealed: Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
2012 NFPA 99, 5.1.14.2.2.5

Review of the following NFPA Standard revealed: Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.4

Review of the following NFPA Standard revealed: A periodic testing procedure for nonflammable medical gas and vacuum and related alarm systems shall be implemented. 2012 NFPA 99, 5.1.14.4.5

Based on observation, interview, and review of the facility's policy, the facility failed to follow accepted standards of practice, by not labeling intra-venous (IV) tubing, for one (Patient 1) of one inpatients receiving IV fluids. Failure to label IV tubing has the potential for the tubing to deteriorate or become contaminated.

Finding Include:

During an observation of Patient 1 receiving services on 12/18/18 at 10:41 AM, a 0.9% Sodium Chloride (salt water) IV bag was hanging and infusing at 75 ml (milliliter)/hr (hour). The IV tubing had not been dated or labeled.

In an interview on 12/18/18 at 10:41 AM, Registered Nurse (RN)1 stated that the IV bag had already been hung when the patient was admitted to acute care (earlier that day). RN 1 stated the tubing should have had a label on it and would be changed out every three days.

In an interview on 12/18/18 at 11:34 AM, the Director of Nursing (DON) stated that when a patient was moved to an acute admit status, or moved from the emergency department or observation status, they would expect the IV fluids and tubing to be labeled already.

In an interview on 12/18/18 at 12:13 AM, the DON stated they were not able to find a policy regarding the labeling of the IV bag and tubing but stated the expectation would be that the IV bag and tubing would be labeled.

Based on interview, record review and review of the facility's policy, the facility failed to obtain a consent to treat one (Patient 1) of one inpatient when the patient was admitted to an inpatient status. This practice has the potential to affect all patients who were admitted to inpatient status.

Findings Include:

Review of the electronic health record, with the Director of Nursing (DON) on 12/19/18 at 8:50 AM, showed Patient 1 had been admitted to the facility through the emergency department on 12/17/18 and placed into an observational status. On 12/18/18, Patient 1 was moved from an observational status to an inpatient acute status.

Review of the facility's policy titled, "Admissions," last revised 10/2018, showed the following, "The admission form (or summary sheet) is filled out or information is directly entered into the (software) system. With consent for medical and/or surgical treatment signed by patient or his/her relative or guardian if he/she is unable to sign.

In an interview on 12/15/18 at 8:50 AM, the DON stated that she was unable to find a consent to treat document signed by Patient 1, after the patient was admitted to the acute setting from the observation setting. The DON stated the facility would require a second consent to treat when the patient was moved from an observation status to an acute status.

Based on interview, record review and review of the facility's policy, the facility failed to obtain admission orders from the physician when one (Patient 1) of one inpatient was moved from an observational status to an acute inpatient status.
Failure to obtain admission orders when a patient changes status has the potential to lead to medical errors and omissions.

Findings include:

Review of Patient 1's electronic health record showed Patient 1 came into the hospital through the emergency department on 12/17/18 and was admitted into observational status. On 12/18/18, the facility transferred Patient 1 to an inpatient acute status.

Review of Patient 1's electronic medical record on 12/19/18 at 8:50 AM, the Director of Nursing (DON) stated that she was unable to locate admission orders for Patient 1, to move from an observational status to an acute inpatient status. The DON stated that the facility did not have a policy that directly addressed admissions orders, but the expectation was that there should be an admission order when a patient was moved from observational status to an inpatient status.

Review of the facility's policy titled, "Admissions," last revised 10/2018, did not address physician's admission orders.