HospitalInspections.org

Based on staff interviews and a review of the current policy, the Critical Access Hospital failed to establish or implement appropriate measures, specific to each department, in the event of a severe weather outbreak. This had the potent to affect both inpatients and outpatients. The hospital reported 239 acute inpatients in 2014.

Findings include:

A. Interviews with 2 radiology staff on 4/1/15 at 11:30 AM regarding their responsibility during a severe weather warning revealed that neither of them knew what they were supposed to do, nor did they know where a designated, safe location, close to their area, was located. A review of the radiology procedure manual confirmed they did not have a policy or procedure to follow regarding severe weather.

B. An interview with the Maintenance Supervisor on 4/2/15 at 10:00 AM revealed the hospital developed a 'facility wide' hazardous weather policy. In part, the policy stated that all non-nursing support staff should report to the nurses station to help transfer patients. This included housekeeping, medical records, laundry, dietary, maintenance, accounting, etc.

C. This policy neglected to identify that non-medical support staff were not qualified to move patients and had not had any training to do so.

D. The policy also failed to address the numerous areas throughout the building that had outpatients being treated, such as Laboratory, Radiology, Physical Therapy and Specialty Clinics, and did not identify any safe areas in or around these locations for patients to be escorted to and sheltered.

Based on medical record review, review of policy, review of Medical Staff Rules and Regulations, and staff interview; the CAH (Critical Access Hospital) failed to ensure that surgical services followed written policy for history and physical examination timeframes in accordance with Medical Staff Rules and Regulations for 2 of 6 surgical patients (Patients 19 and 20) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of procedures performed at the CAH on a monthly basis is 11.

Findings are:

A. Review of Patient 19's medical record on 3/31/15 at 3:40 PM, revealed the patient had repair of an umbilical hernia on 12/30/14. The history and physical examination was dated 11/25/14, thirty-five (35) days before the scheduled procedure.

- Review of Patient 20's medical record on 4/1/15 at 8:15 AM, revealed the patient had repair of an umbilical hernia on 9/16/14. The history and physical examination was dated 8/6/14, forty (40) days before the scheduled procedure.

B. Review of the policy titled Patient History and Physical Examination (reviewed 7/14) stated under Patient Responsibilities: "To make an appointment with his or her regular physician to have a history and physical examination done within 10 days of scheduled procedure."

C. Review of the Rules and Regulations (approved 12/14) stated under OR (operating room) Patients "For patients going to the to O.R., the following is required: History and Physical (may be performed up to 7 days prior to admission),..."

D. Interview with the Operating Room Supervisor on 4/1/15 at 9:15 AM confirmed that the above policy does not follow the Rules and Regulations and that the above surgical medical records history and physicals do not meet the timeframes set out in accordance with the Medical Staff Rules and Regulations.

Based on observation, review of checklist, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to remove outdated medications from 3 of 3 crash carts located in the hospital to prevent administration to patients. Patient census on first day of survey was 11 (7 acute inpatients and 3 swing bed patients).

Findings are:

A. Observation on 4/2/15 at 10:00 AM with the Director of Nursing in the Chemotherapy/Cardiac outpatient services room crash cart revealed:

2-Metoprolol (treats high blood pressure and chest pain) 5mg (milligram)/5ml (milliliter) vials with an expiration date of 2/15;
1-Dobutamine (increases cardiac function) 250mg per 20ml vial with an expiration date of 3/1/15; and
2-Adenosine (used to treat irregular heartbeat) 6mg/2ml vials with an expiration date of 3/15.

Observation on 4/2/15 at 10:15 AM with the Director of Nursing in Room 111 (Critical Care Room) revealed:

2-Adenosine 6mg/2ml vial with an expiration date of 3/15.

Observation on 4/2/15 at 10:20 AM with the Director of Nursing in Room 100 (Critical Care Room) revealed:

2-2% Lidocaine HCL (local or regional anesthetic) 100mg vials with expiration date of 3/1/15, and
2-Dobutamine 250mg per 20ml vials with an expiration date of 4/1/15.

B. Review of the form titled Medroom/CCU (critical care unit) checklist for the year 2015 stated "All checks should be done by the night shift". The list revealed "Check crash carts for outdates monthly". The crash carts in Rooms 100 and 111 have been initialed as checked for January, February and March. The crash cart in the Chemotherapy/Cardiac outpatient services room was initialed as checked for the month of February only.

B. Review of policy and procedure titled Supportive Pharmacy Personnel Outline of Duties (no date) stated that "Monthly duties of the nursing staff will include: 3. Check crash carts for outdates."

C. Interview with the Director of Nursing on 4/2/15 at 10:30 AM confirmed the above outdated medications in the crash carts and stated that "census has been high and the nurses have not had time to check all the crash carts".

Based on a review of the manufacturer's recommendations as compared with the quality control worksheets and confirmed through staff interview, the Radiology staff failed to follow the manufacturer's recommended frequency for performing the phantom on the Computerized Axial Tomographic scanner (CAT). (A CAT scanner captures 2 dimensional images using radiation to 'slice' through areas of the human body.)
(A phantom is a device provided by the manufacturer that mimics the density and configuration of the human head and body. This device has pre-established numerical value ranges, so that when placed in the scanner and subjected to radiation, these values reflect whether the instrument is functioning properly.)

Findings include:

A. A review of the CAT scanner manufacturer's instruction manual page 4.3 titled, "Schedule of quality assurance checks" specified, "Daily checks should be done to ensure the best possible image quality from your scanner. The procedures for daily checks cover these areas:
Noise-on head phantom, water layer.
Noise and artifacts-on body phantom"

B. An interview conducted with the CAT Tech on 4/1/2015 at 10:30 AM revealed the phantom control was performed one time per week.

C. A review of the phantom worksheet for the time period January - March 2015 confirmed the control was performed weekly rather than daily, as specified by the manufacturer.

This had the potential to affect all patients receiving CAT scans on the days the control phantom was not performed. The hospital reported 239 acute inpatients in 2014.

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to have accurate documentation that surgical patient medical records contained the pre-surgical physical examination to evaluate for the risk of the procedure to be performed by the physician for 3 of 6 surgical patients (Patients 17, 18 and 21) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of procedures performed at the CAH on a monthly basis is 11.

Findings are:

A. Review of Patient 17's medical record on 3/31/15 at 2:40 PM, revealed the patient had incision and drainage of a perirectal abscess on 3/11/15. Review of the entire electronic medical record revealed no evidence of physician documentation for the patient's appropriateness for the planned procedure.

- Review of Patient 18's medical record on 3/31/15 at 3:05 PM, revealed the patient had septoplasty (surgical procedure to straighten the nose) on 2/6/15. Review of the entire electronic medical record revealed no evidence of physician documentation for the patient's appropriateness for the planned procedure.

- Review of Patient 21's medical record on 4/1/15 at 8:50 AM, revealed the patient had incision and drainage of the right knee on 7/10/14. Review of the entire electronic medical record revealed no evidence of physician documentation for the patient's appropriateness for the planned procedure.

B. Interview with the Operating Room Supervisor on 4/1/15 at 8:40 AM, confirmed the lack of documentation for the appropriateness of the planned procedure for each of the above patient medical records.

Based on the Critical Access Hospital's failure to perform an annual program evaluation since 2010, failure to evaluate the utilization of services (C-331,), failure to determine if the utilization of services were appropriate (C-332), failure to determine if policies were followed and failure to determine if changes were needed (C-335), failure to take corrective action, if needed (C-341) and failure to implement or document remedial action identified through the quality assurance program (C-342), the Condition of Periodic Evaluation and Quality Assurance Review is not met.

Based on staff interviews and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as current patients of the CAH.

Findings include:

A. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time".

B. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

C. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.
Furthermore, the CAH failed to determine the utilization of services, including the number of patients served and the volume of service.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as current patients of the CAH.

Findings include:

A. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time".

B. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

C. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed that the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.
Furthermore, the results of clinical record reviews could not be determined, since the evaluation was not performed.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.

Findings include:

A. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time".

B. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

C. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed that the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.
Furthermore, since the evaluation was not conducted, a determination as to whether the utilization of services were appropriate, policies were followed, or if changes were needed, could not be determined.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.

Findings include:

A. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time".

B. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

C. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed that the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.
In addition, since the CAH failed to perform an evaluation, staff could not consider the findings, or take corrective action, if required.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.

Findings include:

A. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time".

B. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

C. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews, a review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.

Findings include:

A. A review of meeting minutes for 2014 and the first 3 months of 2015 of Quality Assurance and infection control data reported to the Medical Staff and Governing Body lacked any evidence of final summaries, evaluations of the data, or initiation of any remedial action taken to correct deficiencies identified through the quality assurance program.

B. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control coordinator indicated that she had not been involved in an annual program evaluation, for a "long time". Furthermore, she had not been asked to provide an accumulated summary of all the data reported by all departments.

C. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

D. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.

Based on staff interviews, a review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.

The CAH reported 239 acute inpatients in 2014. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.

Findings include:

A. A review of meeting minutes for 2014 and the first 3 months of 2015 of Quality Assurance and infection control data reported to the Medical Staff and Governing Body lacked any evidence of final summaries, evaluations of the data, or initiation of any remedial action taken to correct deficiencies identified through the quality assurance program. Therefore, the CAH failed to document any outcome related to remedial action.

B. On 4/1/2015 at 4:00 PM an interview with the Quality Assurance and Infection Control Coordinator indicated that she had not been involved in an annual program evaluation, for a "long time". Furthermore, she had not been asked to provide an accumulated summary of all the data reported by all departments.

C. On 4/1/2015 at 5:30 PM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program, that he could recall.

D. An interview on 4/2/2015 at 10:45 AM with the Director of Nursing Services revealed the last annual periodic evaluation was conducted by the former administrator in 2011 for fiscal year 2010.