HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of eight patients. Based on policy review, clinical record review and staff interview nursing staff failed to follow hospital policy for blood administration for two of three sampled patients that received blood (#'s 13 and 15).

Findings include:

- The CAH's policy for Blood Transfusion reviewed on 2/21/12 at 1:15pm, directed "...To provide guidelines for the safe administration of a blood product ...and minimize the risk of adverse reaction to a blood product...record time started ...rate 75cc and hour. Observe patient closely for the first 15 minutes...May increase rate to 125cc an hour if no reactions are noted within the first 15 minutes...Documentation in the patient record should include: date and time blood product started and discontinued, type and gauge of needle, flow rate of blood and IV solution...".

- Patient #13's clinical record reviewed on 2/20/12 at 11:10am revealed an admission date of 2/20/12 with diagnoses of Urinary Tract Infection, Lethargy and recent fall. The patient had low hemoglobin on 2/20/12 and the physician ordered a transfusion of two units of packed red blood cells. Patient #13's clinical record, reviewed on 2/21/12 at 1:15pm, revealed nursing documentation of the first unit of packed red blood cells began on 2/20/11 at 11:09am. The clinical record lacked documentation of the rate of administration for the first unit of packed red blood cells. Nursing documentation for the second unit of packed red blood cells indicated a start time of 2/20/12 at 1:50pm at a rate of 150cc an hour. The Registered Nurse (RN) failed to follow the CAH's policy for the rate of infusion of the blood.

Staff C interviewed on 2/21/11 at 1:15pm acknowledged nursing documentation for patient #13 failed to include the rate of administration for unit #1 and documentation for unit #2 indicated the RN failed to follow the CAH ' s policy for the rate of infusion of the blood.

- Patient #15's clinical record review on 2/20/12 at 3:45pm revealed an admission date of 8/16/11 with abdominal pain. The patient had low hemoglobin on 8/16/11 and the physician ordered a transfusion of two units of packed red blood cells. Nursing documentation for the second unit of packed red blood cells indicated a start time of 8/16/11 at 8:55pm at a rate of 250cc an hour. The Registered Nurse (RN) failed to follow the CAH's policy for the rate of infusion of the blood.

Administrative staff A interviewed on 2/21/12 at 4:10pm acknowledged patient #15's clinical record indicated unit #2 packed red blood cells started at a flow rate of 250cc an hour and the RN failed to follow the CAH's policy for the rate of infusion of the blood.

The Critical Access Hospital (CAH) reported a census of eight patients. Based on observation, staff interview and policy review the CAH failed to conduct preventative maintenance for one of one kitchen range hood.

Findings include:

- Observation on 2/22/12 at 9:00am in the dietary department revealed a heavy accumulation of greasy debris on the inside surface of the range hood.

Dietary staff D interviewed on 2/22/12 at 9:00am acknowledged the greasy debris on the inside surface of the range hood. Staff D acknowledged the department failed to have a routine maintenance schedule for cleaning of the range hood. Staff D failed to have documentation of the last cleaning of the range hood.

- The CAH's policy for cleaning of the range hood reviewed on 2/22/2 at 3:55pm failed to direct staff on when to clean the range hood.

The CAH failed to have a system in place to assure preventative maintenance of the dietary range hood.

The Critical Access Hospital (CAH) reported a census of eight patients. Based on observation, document review and staff interview, the CAH failed to properly store intravenous and irrigation solutions in two of two warming cabinets.

Findings include:


- Manufacturer's information, reviewed on 2/21/12 at 10:30am, revealed the IV fluids "may be warmed not to exceed 104 degrees F (Fahrenheit)" and the expiration date of the fluid is decreased when warmed.

- The Emergency Room, observed on 2/21/12 at 8:30am, revealed a warming cabinet in the main treatment room. The warming cabinet contained a 1000cc (cubic centimeter) bag of normal saline intravenous (IV) fluid and a 1000cc bag of lactated ringers (an electrolyte solution) IV fluid. The thermometer in the warming cabinet displayed the temperature at 110 degrees F. The IV fluid bags lacked the date the fluids were placed in the warming cabinet. Staff E, interviewed on 2/21/12 at 8:30am, confirmed the fluids were stored at 110 degrees F and lacked the date the fluids were placed in the warmer.





25604

- The manufacturer's information sheet for Hospira irrigation solutions reviewed on 2/21/12 at 2:15pm directed "... solutions for irrigation may be warmed up to temperatures not exceeding 40 degrees centigrade (104 degrees Fahrenheit) and for a period no longer than two weeks (14 days)..."

- Observation in the surgical suite on 2/21/12 at 10:45am revealed a warming cabinet. The temperature of the warming cabinet registered 114 degrees Fahrenheit. The warming cabinet contained the following:
1. Twelve 1000cc containers of sterile water irrigation solution.
2. Ten 1000cc containers of sterile Sodium Chloride 9% irrigation solution.
3. Two 3000cc containers of sterile water irrigation solution.
4. Two 3000cc containers of Sodium Chloride 9% irrigation solution.

The warmed solutions lacked a date when placed in the warmer and/or when to remove from use.

Administrative staff B interviewed on 2/21/12 at 10:45am acknowledged the warmed solutions lacked a date when placed in the warmer and/or when to remove from use. Staff B could not assure the safety of the fluids.

- The manufacturer's instructions for Cavicide (a disinfectant), reviewed on 2/22/12 at 4:15pm, revealed the disinfectant must remain in wet contact with the surface for three minutes to disinfect the surface.


- Sterile processing, observed on 2/21/12 at 10:10am , revealed staff J with a covered, wheeled cart containing surgical instruments for sterile reprocessing. Staff J pushed the cart to the soiled area of the processing room and removed the surgical instruments from a bin lined with a plastic bag. After the instruments were removed, the plastic bag was removed and discarded. Staff J applied Cavicide to the surface of the bin and wiped the bin with a dry cloth. Staff J, interviewed on 2/21/12 at 10:10am, acknowledge the disinfectant is to remain in wet contact with a surface for three minutes to disinfect.



25604

The Critical Access Hospital (CAH) reported a census of eight patients. Based on observation, staff interview, and document review the CAH's infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of one observed cleaning of the operating room and one of one observation in sterile processing.

Findings include:

- The CAH's policy "Infection Control Surveillance" reviewed on 2/21/12 at 1:30pm directed "...There will be an established plan for hospital infection control surveillance developed by the Infection Control Nurse..Determine the appropriate type of surveillance needed for areas of Infection Control..."

- Staff K interviewed on 2/21/12 at 1:00pm verified they were responsible for the management of the infection control program. Staff K acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control. Staff C's infection control surveillance is based on patient assessment, antibiotic use, and lab reports to track patient infections.

- The manufacturer's recommendation for "Pheno-Cen" germicidal cleaner reviewed on 2/21/11 at 2:15pm directed for disinfection "...allow the disinfectant solution to remain on surfaces (wet) for 10 minutes..."

- Staff G, staff H and staff I, observed on 2/21/12 between 10:00am to 10:30am cleaned operating room #3 of the surgical suite. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation. For example:

Staff G, staff H and staff I using "Pheno-Cen" germicidal cleaner cleaned the cautery machine (used to stop bleeding during surgery), anesthetic machine, cardiac monitor, bed cushions, and bed base. The surfaces failed to remain wet for the required 10 minutes for disinfection.

Administrative staff B interviewed on 2/21/12 at 10:30am acknowledged the surfaces failed to remain wet the required 10 minutes for disinfection.

The Critical Access Hospital (CAH) reported a census of eight patients. Based on Medical Staff Rules and Regulations review, medical record review, and staff interview the CAH failed to assure medical staff date and/or time all authenticated (signed) entries in the medical record for 28 of 32 patient medical records reviewed (patient's #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30).

Findings include:

- The Medical Staff "Rules and Regulations" reviewed on 2/22/12 at 9:50am directed "All orders shall be in writing with date and time..."

- Patient #19's medical record reviewed on 2/20/12 revealed an admission date of 2/15/12 with a right hip open wound. Patient #19's medical record revealed between 2/15/12 to 2/20/12, one order written by the provider lacked a time when authenticated and ten telephone/verbal orders lacked a date and time when authenticated by the provider.

- Patient #23's medical record reviewed on 2/21/12 revealed an admission date of 1/25/12 with a diagnosis of newborn. Patient #23's medical record revealed between 1/25/12 to 1/27/12, one History and Physical, one Discharge Summary, and one Post Partum Vaginal Delivery orders lacked a date and time when authenticated by the provider.

- Patient #28's medical record reviewed on 2/21/12 revealed an admission date of 11/18/11 with diagnoses of Pneumonia and Post Left Knee Arthroplasty. Patient #28's medical record revealed between 11/18/11 to 11/28/11, one History and Physical, one Discharge Summary, one pre-printed admission orders, one Bowel Care Standing orders, and three telephone/verbal orders lacked a date and time when authenticated by the provider.

Administrative staff A interviewed on 2/22/12 at 10:05am acknowledged the CAH failed to assure medical staff dated and timed all entries in the medical record when authenticated.

This deficient practice also affected patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 18, 20, 21, 22, 24, 25, 26, 27, 29, and 30.