HospitalInspections.org

28649

Based on interview and document review the facility failed to develop provisions for emergency fuel supply if access was shut off to the community. This had the potential to affect all 13 of 13 patients being treated at the facility.

Findings include:

An email dated 5/14/12 at 12:44 p.m. from the maintenance director (MD) to maintenance-B revealed, "I need you to search for a company that would be able to supply the hospital in an emergency for FUEL SUPPLY. Being a Critical Access Hospital we need to have some source of getting fuel to our facility. Will you please start researching this for me while I am gone? You can either email me info or bring it to me next week." A response by maintenance-B on 5/15/12 at 8:52 a.m. noted he contacted Como oil and they would do what ever was needed for Lakeview in regards to fuel oil. Maintenance-B provided Como oil's contact information for MD to set up a contract/agreement. The MD confirmed she had not followed up on the email and no policy had been developed.

Based on observation, interview, and document review, the Critical Access Hospital (CAH) failed to ensure that all drugs and biological's were secure in the radiology and emergency departments having the potential to affect 13 of 13 patients being treated.
Findings include:
During observation at 10:32 a.m. on 6/6/12 a tour of the computed tomography (CT) room was completed. The CT room had emergency medications stored in a cabinet labeled "emergency medication." The cabinet had a zip tie lock on the handles of the cabinet doors.
During interview at 3:01 p.m. on 6/5/12 the director of radiology (DR)-A reported it was impossible to break the lock with your hands but a scissors may be used to break the lock. DR-A stated the door to the CT room was locked from 7:30 p.m. to 6:00 a.m. (non-service hours). However, DR-A reported the door leading into the CT room from the CT observation room was not locked. DR-A also confirmed the door to the observation room was not locked during non-service hours. DR-A verified the facility housed a chemical dependency outpatient program on the first floor.
The Drug Kit policy revised 9/7/04, identified the purpose was to make sure the proper drugs were kept securely locked at all times. The policy identified that the inventory checklist for emergency drug kit included: Nalaxone hydorcholoride injection syringe, nitrostate tablets, Diphenhydramine, Solu-medrol, adrenaline, Solu-Cortef, Epinephrine, Lidocaine, Atropine, and Aromatic Ammonia.


27598

On 6/6/12, at 9:05 a.m. a tour of the emergency department (ED) was completed. 3 ED bays were observed to be unattended by staff and in close proximity to the ED public entrance door which was open. Observed in the ED bay was a crash cart with a plastic break away lock that could be removed by pulling at the device. No other lock was observed on the cart. The cart contained lifesaving medications such as atropine (an anticholinergic), ketamine (an anesthetic), lidocaine (an antiarrhythmic) as well as many other medications. At 9:50 a.m. the director of nursing (DON) stated patients will not always be under direct supervision while in the ED due to the nursing staff being responsible for both the ED and acute care unit patients. The DON verified the public door was open and the ED was unlocked with the crash cart in that immediate area. The DON stated there has been no problems with unauthorized access to the crash cart but could see the concern.

On 6/7/12, at 1:20 p.m. the pharmacist stated the crash cart is monitored daily but agreed with this concern about the security of the medications. The pharmacist further verified the concern related to the security of the CT room medication storage.


12831

Based on observation, policy review and staff interview, the critical access hospital (CAH) failed to ensure sanitary conditions were provided in the out patient surgery department for 1 of 2 outpatients (OP-2) observed to receive the colonoscopy, an invasive procedure. This had the potential to affect all colonoscopy patients except for the first patient of the day.

Findings include:

Outpatient (OP-2) was not provided infection control procedures during a colonoscopy procedure on 6/06/12.

On 6/06/12, at 8:15 a.m. OP-1 was observed to be prepared for a colonoscopy procedure with assistance from RN-
C and surgical technicians (ST-A) and (ST-B). ST-B wore a lab coat and stood by physician-C during the procedure. At 8:20 a.m. physician-C donned a laboratory coat over his street clothes and utilized a gastrointestinal (GI) scope to observe OP-1's colon and removed one polyp. The colon was visualized to bleed on the monitor screen. Physician-C was observed to insert and withdraw the scope several times as he visualized the colon. ST- B left her laboratory coat on as she cleaned the scope. Physician-C put his lab coat over a stool which allowed it drape on the floor.

On 6/06/12, at 9:00 a.m. OP-2 was observed to be prepared for a colonoscopy procedure with assistance from RN-
C and ST-A and ST-B. At 9:05 a.m. Physician-C arrived and donned the lab coat hanging on the chair from OP-1. ST-B wore the same lab coat and stood by the physician during the procedure. The GI scope was utilized to observe OP-2's colon and, beginning at approximately 9:20 a.m., three polyps were removed with bleeding visualized on the monitor screen. Physician-C was observed to insert and withdraw the scope several times as he visualized the colon.

On 6/6/12, at 9:50 a.m., physician-C indicated that he felt uncomfortable wearing the same lab coat for more than one patient during colonoscopy procedures. On 6/6/12, at 10:30 a.m. the surgical service coordinator (SSC) stated they have been doing this for years and hadn't thought about it before. She confirmed an infection to patients could occur. Upon request, the SSC stated there was no policy related to changing lab coats between patients.

Based on observation, interview and document review, the critical access hospital (CAH) failed to properly sanitize equipment in the dietary department. This had the potential to affect all 13 of 13 patients in the CAH. Findings include:

During an environmental tour on 6/6/12, at 10:17 a.m. the Scotsman ice machine was observed to have a long drain pipe emptying into a drain in the floor. On the end of the drain there was film build up. The grill vents above the grill and stove top where food was prepared were heavily soiled with dark color build-up and dust. Dietary aide (DA)-A confirmed the findings. DA-A stated she was not sure the last time the vents were cleaned, but thought it was done every fall and spring. DA-A reported the vents were not on the kitchens cleaning log.

During interview on 6/6/12, at 3:30 p.m. maintenance-B stated he was responsible for sanitizing the ice machine. Maintenance-B stated he was not instructed to sanitize the internal components of the ice machine and had not been completing this task. Maintenance-B confirmed the manufacturer's instructions directed sanitizing the internal components.

The Scotsman product manual dated 5/01 identified the water system need to be sanitized and cleaned. It noted to mix eight ounces of Scotsman ice machine cleaner and three quarts of hot potable water. It then instructed to pour the water into the reservoir, wait 15 minutes for the cleaner to dissolve the minerals inside the evaporator, plug-in the machine or reconnect electrical power. It noted as the machine operates, pour the balance of the cleaning solution, reconnect the water supply, operate the machine for 15 more minutes then switch it off. It further instructed to repeat these steps except substitute a locally approved sanitizing solution for the cleanser. Also, it indicated a sanitizing solution needed to be poured down the drain that connected the ice machine to the drain to sanitize this as well.


12831

Based on document 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 15 of 33 patient records (outpatients #3, #4, #5; inpatients #4, #20, 310, #12, #15 ; and emergency department patients #3, #4, #5, #6, #8, #9, #19) reviewed.
Findings include:

OP3 was admitted to the CAH on 4/16/12, for surgery umbilical , epigastric, inguinal repair. The hand written routine surgery pre-operative and post operataive physician's orders dated 4/16/12, but the time was not documented..

OP4 was admitted to the CAH on 5/21/12, for left eye surgery. The Standing Physician's Orders dated 5/21/12, lacked a timed physician signature.

OP5 was admitted to the CAH on 5/15/12, for right carpal tunnel release. The standing orders dated 5/15/12 were not timed by the physician. The orthopedic post operation orders dated 5/15/12 were not sided by the physician. The surgical antimicrobial prophylaxis was not timed, dated nor did it have a physician signature.

On 6/7/12, at 10:30 a.m. the surgical service coordinator stated that none of the hand written out patient surgical orders include the time they were written.



27598

P4 was admitted on 5/2/12, with cellulitis. The physician orders dated 5/2/12 lacked a time of the entry. The Sliding Scale Insulin Orders lacked a date, time and signature of the physician.

P20 was admitted on 2/3/12, with aspiration pneumonia. The history and physical lacked a date, time and signature of the physician.

Emergency department patient (EDP)-2 was seen in the emergency department (ED) on 4/23/12, for abdominal pain. The Emergency Room Record lacked a dated, time and an electronic signature from the physician. The physcian orders lacked a dated, time and signature. The Observation Orders lacked a time of the orders.

EDP-3 was seen in the ED on 3/23/12, for mental health concerns. The Discharge Summary and Emergency Room Record lacked a date, time and an electronic signature of the physician. The ED orders lacked a dated and time of the orders.

EDP-4 was admitted on 3/27/12, for intoxication. The Emergency Room Record lacked a dated, time and an electronic signature from the physician.

EDP-5 was admitted on 3/16/12, with a laceration. The Emergency Room Record lacked a dated, time and an electronic signature from the physician until 5/23/12.

EDP-6 was seen in the ED on 3/15/12, for rash. The Emergency Room Record lacked a dated, time and an electronic signature from the physician.

EDP-8 was seen in the ED on 3/3/12, for a head injury. The Emergency Room Record lacked a dated, time and an electronic signature from the physician until 5/23/12.


EDP-9 was seen in the ED on 3/3/12, for a laceration. The Emergency Room Record lacked a dated, time and an electronic signature from the physician until 5/23/12.


EDP-10 was seen in the ED on 3/9/12, for a cardiac arrhythmia. The Emergency Room Record lacked a dated, time and an electronic signature from the physician until 6/1/12. The ED orders lacked a dated and time of the orders.


28035



P10 was admitted to the CAH on 4/12/12, for aspiration pneumonia. The verbal Physician's Orders dated 4/14/12, and 4/17/12, lacked a timed and dated signature by the physician.

P12 was admitted to the CAH on 12/20/11, for congestive heart failure. The verbal Physician's Orders dated 12/22/11, lacked a timed and dated physician signature.

P15 was admitted to the CAH on 3/1/12, for pneumonia. The dictated Emergency Room Record dated 3/1/12, lacked a timed and dated physician's signature.

P20 was admitted to the CAH on 2/22/12, for pancreatitis. The 9:30 a.m. and 10:30 a.m. verbal Physician's order dated 2/22/12, lacked a timed and dated physician's signature. The 2/23/12, 0830, 1230, and 1400 verbal Physician Orders lacked a timed and dated physician signature. The 2/29/12, 1445, and 1455 verbal Physician Orders lacked a timed and dated physician signature. The 3/9/12, 1040 verbal Physician Order lacked a timed and dated physician's signature. The 3/10/12, verbal Physician Order lacked a timed and dated physician signature.

The Bylaws Rules and Regulations of The Medical Staff dated 11/17/09, indicated all physician orders for therapeutic and diagnostic services and medications shall be in writing and authenticated within 24 hours. The Bylaws also indicated the medical records of all patients shall be complete within 30 days form the date of the patient's discharge.

On 6/7/12, at 4:15 p.m. the Director of Medical Records stated all physician orders and progress notes were no longer required to be authenticated within 24 hours, however, were required to be authenticated within 30 days.

Based on record review and interview the facility failed to monitor quality assurance (QA) programs for 10 of 21 departments of the CAH, including pharmacy, infection control, medications errors, nursing, chemical dependency, outpatient surgery, laboratory, cardiac out patients, organ procurement services and swing bed services. This had the potential to affect all patients of the CAH.

Findings include:

The facility Quality Assurance (QA) program did not address all provided services. There was no tracking of QA programs since October 2011. The quality improvement (QI) manager, interviewed on 6/7/12, at 3:45 p.m., stated she was new as of March 2012 and was not sure which departments had effective QA activities.

Review of the Quality Improvement (QI) Plan, last reviewed by the facility on 2/11, indicated the QI coordinator had overall authority and responsibility to carry out the functions of the QI program. Data was to be collected by the Department supervisors and reviewed with the QI coordinator. The QI coordinator would generate a QI summary report and share it with the QI Committee, administration, medical staff and board.

Review of the quarterly QA minutes with QI coordinator confirmed the minutes were not clear enough to determine what departments had appropriate QA programs. Review of the ongoing monitoring of the Departmental Quality Improvement 2011 monthly reports indicated that monitoring of QA had ended in October 2011. There were no 2012 Departmental monthly QA reports available. The QI coordinator indicated the person who was in charge of QA had resigned in October 2011 and no one had coordinated the QA programs since that time.

Review of the individual departments and services for QA programs indicated:

ORGAN TISSUE AND EYE PROCUREMENT
The QI coordinator was interviewed on 6/7/12, at 3:45 p.m. and stated she did not know if the services for organ procurement had been evaluated as part of the CAH QA program. The CAH had data provided to them from Life Source (organ and tissue donation organization) but did not identify quality and performance problems, or implement improvement activities. The January 17, 2012 executive committee and medical staff minutes indicated that staff needed more education on donation referrals. Interview with the DON on 6/7/12, at 9:45 a.m. indicated the information she received from LifeSource on the donation activity was the QI.

CARDIAC OUT PATIENT CLINIC
The CAH collected data regarding patient success in meeting goals for new cardiac procedural protocols since 2009; however, there were no interventions other than standard physician's post operative orders. The goal was for the patient to meet or exceed goals established on admission. Interview with the RN in charge of cardiac rehabilitation on 6/7/12, at approximately 2:45 p.m. indicated that they would encourage the patients to do the protocols depending on the patient's needs.

SURGERY
Interview with Surgery Service Coordinator on 6/7/12, at 1:15 p.m. confirmed there was no QA program for outpatient surgery. She added they had been checking outdates on intra venous solutions since 2009. She confirmed that was not a QA program but monitoring of IV solutions.

Chemical Dependency:
On 6/7/12, at approximately 11:00 a.m. the director of the outpatient CD program stated there was no QA program for the CD services.

Lab
On 6/7/12, at approximately 9:00 a.m. the lab coordinator (LC)-A stated there was no QA program for laboratory services.

Swing bed
On 6/7/12, at approximately 1:30 p.m. the director of nursing verified there was no QA program for swing bed services.


27598

Pharmacy:
On 6/7/12, at 1:20 p.m. the licensed pharmacist (LP) reviewed the QA program. Daily charges were reviewed by the pharmacist to prevent inaccurate charging to the patients. The goal was to remain at 99% accuracy of charging. No ongoing monitoring, data collection, corrective actions, or evaluations of corrective actions were documented. The LP stated these components were missing from the pharmacy QA.

Based on interview and document review the critical access hospital (CAH) failed to ensure 14 of 20 registered nurses (RN, a,b,d,e,f,g,h,i,j,k,l,m,n) received ongoing education regarding organ donation issues; and failed to incorporate data related to the organ procurement organization (OPO) and tissue including eye bank into the Quality Improvement program for evaluation.

Findings include:

Review of staff education and in-service materials for OPO training from 6/1/11, through 6/7/12 revealed 6 RNs had training related to organ donation issues during this time. Interview with the director of nursing services on 6/7/12, at 9:45 a.m. confirmed OPO training did not occur for the new hires in 2011 and 2012. The DON indicated RN-i, RN-m, and RN-n, hired in 2011, had not been provided with information related to organ procurement donation. The DON verified the lack of documented OPO education for RNs (a,b,d,e,f,g,h,j,k,l,). She confirmed they had only been educating the registered nurses and did not educate all other direct care staff.

Review of the Quality Improvement (QI) minutes revealed no integration of the OPO data into the QI Plan was noted. Although the OPO had provided documentation to the CAH related to deaths reported for potential donation from January of 2011 through December of 2011. The information received from the OPO had not been reported as part of the QI program. There was no evidence that the CAH had evaluated current protocols to determine effectiveness of their policy's and program. Interview with quality assurance RN on 7/7/12, at 2:40 p.m. confirmed she did not know if OPO was not included in their Quality Improvement plans. Review of the 2011, and QI minutes indicated that OPO had not been addressed.