HospitalInspections.org

36293

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 9 of 25 of the hospital's total patient beds.

Findings:

Observation of the CAH patient ward on 4/30/18 at 11:40 a.m. revealed the call buttons on the bed's side rails in patient room 208 and patient room 212 did not function.

A follow-up observation of the ward, accompanied by S32RN, on 4/30/18 at 1:00 p.m. revealed the call buttons on the bed's side rails in patient room 208 and patient room 212 did not function. During an interview on 4/30/18 at 1:15 p.m., S32RN acknowledged the call buttons on the patient beds in rooms 208 and 212 did not function.

On 05/02/18 at 12:30 p.m., interview with S1DON confirmed that the hospital had 9 patient beds that had nurse call buttons on the handrails that did not function.

Based on record review and interviews the CAH (Critical Access Hospital) failed to meet the requirements of the Condition of Participation for Provision of Services as evidenced by the registered nurse failing to supervise and evaluate the care provided to patients by failing to ensure continuous monitoring for 2 (#5, #6) of 4 (#5, #6, #9, and #10) diagnosed with suicidal thoughts. Patient #5 and #6 eloped from the ED. Patient #6 eloped from the ED two times within one hour and nine minutes due to the lack of continuous patient monitoring as detailed in the hospital policy. Neither Patient #5 or Patient #6 were found after their elopement. (See tag C-0296).

Based on interview and record review, the hospital failed to ensure the dispensation and administration of drugs and biologicals was implemented in accordance with accepted professional principles, hospital policy and the Louisiana State Board of Pharmacy as evidenced by failing to ensure the hospital practice for dispensing and administering medications and biologicals followed the requirements of the Louisiana Board of Pharmacy regarding the pharmacist's review of medication orders prior to the first dose being administered except in emergencies.
Findings:

Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part LIII: Pharmacists Chapter 15. Hospital Pharmacy" revealed that the pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the hospital policy titled, Medication Verification, revealed in part that the pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency. This means any medication ordered by the physician must be placed on the MAR (medication administration record) by the nurse, and then must be verified by the pharmacist prior to being administered.

On 05/01/18 at 1:45 p.m., an interview with S33Pharmacist revealed the pharmacy is open daily from 8:00 a.m. until 5:00 p.m. He stated that the hospital has a contract with Hospital A to perform first dose reviews of medications after pharmacy hours. S35Pharmacist stated that after 5:00 p.m., if patients receive a new medication order, the nurses are to fax the information over Hospital A pharmacy and wait for verification before administering the first dose of the medication. When asked if this process was occurring, he stated "sometimes".

At this time, a log was requested of new medications that were ordered by the physician after pharmacy hours. Review of the log revealed that Patient #1 received a new order for Maxipime 1 gram intravenous on 05/01/18 (after pharmacy hours). The log revealed that Pharmacy A verified the medication order on 05/01/18 at 2:19 a.m. S35Pharmacist pulled the patient's MAR up on his computer and confirmed that the patient was administered the first dose of the medication on 05/01/18 at 2:00 a.m., prior to the verification by the pharmacist at Hospital A.

Further review of the log revealed that Patient #R1 received a new physician order for Zosyn 3.375mg intravenous on 04/10/18. The first dose was administered on 04/10/18 at 3:30 a.m., but the medication was not verified by a pharmacist until 04/10/18 at 8:06 a.m.








36293

Based on observation and interview, the Critical Access Hospital failed to ensure that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.

Findings:

Observation of the Intensive Care Unit medication room on 4/30/18 at 12:35 p.m. revealed a 500-milliliter bag of 3% normal saline with an expiration date of November 2017.

During an interview on 4/30/18 at 12:38 p.m., S33RN acknowledged expired medications should not be available for patient use.

Based on record review and interview, the CAH failed to ensure that the physician was notified of identified medication errors and that the errors were documented in the patient's medical record for 2 (Patient #20, 21) of 2 hospital identified medication errors reviewed.
Findings:

Patient #20
Review of the hospital's Drug Variance form for patient #20 dated 01/29/18 revealed that the physician wrote an order for the patient to receive 1/2 normal saline at 100 cc/hr intravenous for 24 hours, but the order was not implemented. Further review of the Drug Variance form revealed in the section indicating physician notifed, "no" was documented. Review of the patient's medical record revealed no documentation regarding the medication error.

Patient #21
Review of the hospital's Drug Variance form for patient #21 dated 01/29/18 revealed that the physician ordered Ativan 1mg by mouth but the patient was administered Ativan 1mg intravenous. Further review of the Drug Variance form revealed in the section indicating physician notifed, "no" was documented. Review of the patient's medical record revealed no documentation regarding the medication error.

An interview was conducted with S1DON on 05/02/18 at 1:45 p.m. She confirmed there was no documentation in the above patients' medical records regarding the medication errors or the physician notification of the medication errors. S1DON further confirmed that the hospital had no policy related to the documentation of medication errors in the patients' medical records.

20310

Based on observation, record review and interview, the hospital failed to maintain a system for controlling infections by: 1) failing to maintain a sanitary environment in the patient's rooms, failing to discard expired paient treatment supplies and failing to maintain a sanitary environment in the surgical area; 2) failing to conduct leak testing on endoscopes; 3) failing to monitor the temperature of the reusable high level disinfectant cleaner used to disinfect endoscopes; 4) failing to maintain a sanitary environment and failing to discard expired patient treatment supplies in the Emergency Room and 5) failing to disinfect the glucometer after patient use.
Findings:

Review of hospital's Policy titled Equipment Department revealed, in part, the following:
Policy: a. When a patient is discharged, housekeeping is called to clean the room and all the equipment used in that room. b. After the room and equipment has been cleaned, the equipment will be covereed by housekeeping with protective covers provided and tagged with a clean sticker.

1. Observation on 4/30/18 at 11:40 a.m. revealed the following:
a. Room 208 - Faucet outlet in patient room wrapped with tape.
b. Room 212 - Bed rail on left side of bed wrapped with tape, Torn fabric to the seat cushion of the chair.
c. Room 223 Torn fabric to seat cushion on the recliner
e. Room 232 Room exhaust blower duct covered with grime, spider and web on the exhaust blower, a spider and web on the wall unit, dead insects on the pillow case and the bedsheets.
f. Room 235 - Torn fabric to seat cushion on the chair.

Observation of the Intensive Care Unit on 4/30/18 at 12:00 p.m., accompanied by S33RN, revealed the following:
a. Room 241 Infusion Room - two 18 gauge angiocatheters with expiration dates of 4/17 and 3/18, approximately twenty 20 gauge angiocatheters with an expiration date of 8/2016.
b. Room 242 - Fingernail on bedside table, broken covering on the left bed rail, trash on the floor next to the patient bed, dirty infusion pump uncovered and not tagged as clean, call bell cord coated with brown substance.
c. Room 251 - Open suction catheter kit
d. Isolation room - PPE vestibule had a bag of dirty laundry and a dirty urinal on the PPE cart.
e. Room 253 - Brown substance on left side rail, old sticky tape debris on both side rails.
f. Room 254 - Heavy layer of dust covering the window blinds, grunge on the bed side rails, dirty infusion pump.
g. The crash cart contained a package of pediatric electrodes with expiration date of 11/2013 and adult electrode pads with expiration date of 2/2018.

During an interview on 4/30/18 at 12:45p.m., S33RN acknowledged patient's rooms 241, 242, 251, 253, 254, and the isolation room, designated as clean, were not sanitized, contained expired patient use items and patient care equipment that had not been sanitized.

During an follow-up observation of rooms 208, 212, 223, 232 and 235 on 4/30/18 at 1:00 p.m., accompanied by S32RN acknowledged the patient rooms, designated as clean, were not sanitized and the furnishings with torn fabrics could not be sanitized.

On 05/01/18 at 11:05 a.m., observation of the surgical department revealed the anesthesia carts located in operating rooms 1 and 2 had pieces of tape covering the drawer pulls in several places. Tape was also noted on other areas of the outside of the carts. There was debris and old spills noted inside the medication drawers of the carts. The blanket warmer had pieces of tape on it and areas of rust.

An interview at this time with S9RN confirmed the anesthesia carts needed to be cleaned, and that the taped and rusted areas were not able to be cleaned and disinfected.

On 05/01/18 at 11:15 a.m., observation of the endoscopy storage cabinet revealed parts of curled up scopes lying flat on a yellowish stained towel on a shelf near the cleaned scopes that were hanging on the wall inside the cabinet. Other parts and pieces of scopes were lying on a towel on the floor of the cabinet under the hanging scopes.
An interview at this time with S7ST confirmed these scope parts were old and no longer in use, and should not be stored with clean scopes.

2. Review of the hospital's policy for cleaning, sterilization and storage of endoscopes revised 05/21/97 and reviewed 06/21/17 revealed in part ...A specific routine for handling, cleaning, disinfecting and storing of equipment is recommended by the manufacturing company and this hospital ...Step II. Leakage Test: Connect the Leakage Tester to the Light Source and then to the scope. Once the scope has been connected to the Leakage Tester, it should be immersed into clean water. If a leak is present, it will be evidenced by bubbling of air.

On 05/01/18 at 11:20 a.m., observation of the decontamination and sterilization area revealed the endoscopes were cleaned and disinfected manually.
During an interview with S7ST at this time, she stated they did not conduct leak tests of the endoscopes and confirmed there was no system in place for leak testing of the endoscopes.

3. On 05/01/18 at 11:25 a.m., observation of the decontamination and sterilization area revealed a dated container of ALDAHOL 1.8 High-Level Disinfectant.
Review of the manufacturer's label revealed the temperature of the reusable disinfectant should be maintained at 20 degrees Celsius when activated for use or re-use.
An interview with S7ST at this time revealed the activated solution is stored for re-use and replaced every 14 days. She confirmed there was no monitoring of the temperature levels of the disinfectant.

4. Observation on 4/30/18 at 2:50 p.m. of the ER trauma bay, accompanied by S2ERSup revealed the following:
a. Thoracentesis kit with an expiration date of 8/2017
b. Four evacuation containers with expiration dates of 1/31/18.
c. Two Pediatric lumbar puncture kits with expiration dates of 9/30/17.
d. Soiled blood warming device that was not sanitized for use left uncovered and not labeled as clean.
An interview at this time with S2ERSup acknowledged the expired medical supplies and the blood warming device that was not sanitized.

5. On 05/02/18 at 10:40 a.m., observation revealed S34CNA entered Patient #11's room to check the patient's blood glucose. Observation revealed S34CNA removed the glucometer from the hard plastic carrying case and placed it on the patient's overbed table while she stuck the patient's finger. She then performed the blood glucose test with the glucometer and then placed it back into the plastic carrying case without first disinfecting it. She was then observed to enter Patient #R2's room and perform the same procedure as above.

On 05/02/18 at 11:00 a.m., S34CNA was asked how often the glucometer was disinfected and she stated once per day.

The (CAH) Critical Access Hospital failed to provide nursing care in accordance with the patient's needs and the specialized qualifications and competence of the staff available by failing to ensure ED Emergency Department staff were trained in nonphysical intervention skills for 9 of 16 ER staff members.

Findings:

Review of S11RN, S13RN, S15RN, S16RN, S18LPN, S19LPN, S20LPN, S21LPN, and S23CNA's personnel files, credentialing files, and MOAB training roster with S4QA failed to reveal training or competence in nonphysical intervention.

During an interview on 5/2/18 at 9:30 a.m., S4QA acknowledged S11RN, S13RN, S15RN, S16RN, S18LPN, S19LPN, S20LPN, S21LPN, and S23CNA received no training and were not competent in nonphysical intervention for the patients treated in the ED.

Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to patients by failing to ensure continuous monitoring for 2 (#5, #6) of 4 (#5, #6, #9, and #10) diagnosed with suicidal thoughts. Patient #5 and Patient #6 eloped from the ED. Patient #6 eloped from the ED two times within one hour and nine minutes due to the lack of continuous patient monitoring as detailed in the hospital policy.

Findings:

Review of the CAH's (Critical Access Hospital's) Policy titled Suicide Precautions in the ED revealed, in part, the following:
Purpose: CAH is committed to providing a safe environment for patients, visitors and employees. Policy: Suicide Risk Screening Exception: A patient who presents with a chief complaint of suicidal ideation ...does not require a screening to determine risk. Initiate suicide precautions immediately for this patient. Procedure: Suicide precautions include ...Continuous observation by clinical staff or security personnel.

Review of CAH's Policy titled Psychiatric/Behavioral Emergency revealed, in part, the following:
Policy: Under no circumstances will the patient be left unattended.
Examples of such emergency may include but is not limited to: 1. Suicidal ideation.

Review of Patient #5's (PEC) Physician Emergency Certificate completed and signed by the physician on 2/18/18 at 2:45 a.m., detailed, in part, the following:
History of Present Illness - suicidal ideation and auditory hallucinations. Currently - Suicidal. Dangerous to self. Unwilling to seek voluntary admission.

Review of Patient #5's Nursing Medical Record revealed, in part, the following:
2/20/18 at 1:15 p.m. - Patient is not in his room and is unable to be found.

During an interview on 5/1/18 at 1:15 p.m., S2ERSup confirmed Patient #5 was unattended after receiving a PEC, eloped from the hospital, and acknowledge the hospital policies were not followed.

During an interview on 5/1/18 at 2:10 p.m., S5RN acknowledged she was the RN on duty at the time Patient #5 eloped and acknowledged the patient was unattended and the hospital policies were not followed.

Review of Patient #6's (PEC) Physician Emergency Certificate completed and signed by the physician on 3/5/18 at 12:00 p.m., detailed, in part, the following:
History of Present Illness - agitated, psychotic and suicidal. Currently - Suicidal. Dangerous to self and gravely disabled. Unwilling and unable to seek voluntary admission.

Review of Patient #6's Nursing Medical Record revealed, in part, the following:
3/6/18 at 4:13 p.m. - Patient has left facility ...and is walking on the highway.
3/6/18 at 5:00 p.m. - Patient brought back by local police department.
3/6/18 at 5:22 p.m. - Patient has left facility again. Patient was not found.

During an interview on 5/1/18 at 1:17 p.m., S2ERSup confirmed Patient #6 was unattended after receiving a PEC, eloped from the hospital twice, and acknowledge the hospital policies were not followed.

During an interview on 5/1/18 at 2:15 p.m., S5RN acknowledged she was the RN on duty both the times Patient #6 eloped and acknowledged the patient was unattended and the hospital policies were not followed.

Based on record review and staff interview, the CAH failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 2 (#12, #13) of 2 patients reviewed for medication administration out of a total sample of 21 patients.
Findings:

Patient #12
Review of the record for Patient #12 revealed an admission date of 04/28/18 with orders for blood glucose checks before meals and at bedtime with Humalog sliding scale insulin per the physician's protocol. Review of the physician's protocol revealed it included the following: blood glucose 61-150, 0 units Humalog; blood glucose 151-200, 3 units Humalog.

Review of the patient's medical record revealed the following:
04/28/18 at 5:00 p.m. - blood glucose 152, 0 units Humalog administered
04/28/18 at 9:00 p.m. - blood glucose 244, 0 units Humalog administered
04/29/18 at 5:00 p.m. - blood glucose 180, 0 units Humalog administered
04/30/18 at 4:58 p.m. - blood glucose 182, 0 units Humalog administered
05/01/18 at 9:52 pm. - no blood glucose result documented

On 05/02/18 at 10:00 a.m., S35RN reviewed the patient's medical record and confirmed that the Humalog sliding scale insulin was not administered as ordered by the physician.

Patient #13
Review of the record for Patient #13 revealed an admission date of 04/29/18 with orders for blood glucose checks before meals and at bedtime with Humalog sliding scale insulin per the physician's protocol. Review of the physician's protocol revealed it included the following: blood glucose 61-150, 0 units Humalog; blood glucose 151-200, 3 units Humalog.

Review of the patient's medical record revealed the following:
04/30/18 at 4:56 p.m. - blood glucose 171, 0 units Humalog administered
05/01/18 at 5:21 p.m. - blood glucose 155, 0 units Humalog administered

On 05/02/18 at 10:30 a.m., S35RN reviewed the patient's medical record and confirmed that the Humalog sliding scale insulin was not administered as ordered by the physician.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the (QA) Quality Assurance program was effective as evidenced by the (QA) program failing to identify problems regarding elopement from the (ER) Emergency Room for psychiatric patients admitted using a (PEC) Physician Emergency Certification.

Findings:

Review of hospital policy titled Incident/Event Reporting revealed, in part, the following:

Policy: It is the policy of the hospital to document and report within a timely manner all events or unusual occurrences as defined in the guidelines set forth in this policy to the appropriate entity.

Purpose: The purpose of event reporting is to enhance the quality of patient care, to assist in providing a safe (risk-reduced) environment for that care...The event reporting policy should be followed with all incidents occurring at the hospital and clinics. Depending on the type of severity of the event, the Ricks Manage/Quality Manager/Administrator "on-call" should be notified immediately.
Other policy purposes are: To serve as an information base for devising corrective measures to preclude reoccurrences.
Procedures: Types of reportable patient/visitor events are as follows:
a. Adverse Event - an unplanned or unusual deviation in patient care process.
c. Sentinel Event - a sentinel event is an unexpected occurrence involving a death or serious injury...or the risk thereof. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Objectives: To provide a factual record of the occurrence so that the care being given can be evaluated and adequate care standards be developed if lacking.

During an interview 5/1/18 at 2:10 p.m., S5RN stated she did not complete an Incident/Event Report for Patient #5 who eloped at 1:16 p.m. on 2/20/18. Patient #5 was admitted 2/18/18 at 2:45 a.m. using a (PEC) Physician Emergency Certification for a diagnosis of Suicidal Ideation.

During an interview on 5/1/18 at 2:10 p.m., S5RN stated she did not complete an Incident/Event Report for Patient #6 who eloped on at 4:13 p.m. and again on 5:22 p.m. on 3/6/18. Patient #6 was admitted 3/5/18 at 12:00 p.m.. using a (PEC) Physician Emergency Certification for a present illness of psychotic and suicidal.

During an interview on 5/2/18 at 10:00 a.m., S4QA stated she did not have Incident/Event Reports for Patient #5 and Patient #6's elopements. S4QA continued to state the Incident/Event reporting is the hospital's only way of detection.

Review of the Emergency Department's February 2018 service register log revealed a patient who arrived on 2/18/18 with a disposition on the log denoted as "eloped".

Review of the Emergency Department's March 2018 service register log revealed a patient who arrived on 3/5/18 with a disposition on the log denoted as "eloped".

Review of the (QI) Quality Improvement ER Volume Statistics for 2018 revealed elopements were not measured.

During an interview on 5/2/18 at 10:00 a.m., S4QA stated she is part of the QA/QI team and performs the Case Management and Risk Management roles for the hospital. S4QA stated they do have not system in place for looking at patient elopement.

During an interview on 5/2/18 at 10:24 a.m., S3QI stated she is the Special Projects manager and does the QI for the hospital. S3QI stated the hospital does not have a system in place to track patient elopement.