HospitalInspections.org

The Critical Access Hospital (CAH) reported a total census of four acute patients and four swing bed patients. Based on observation, Statement of Deficiency review, policy review, and staff interview the CAH failed to ensure equipment and supplies commonly used in life-saving procedures were readily available to staff in two of three Emergency Department (ED) rooms and one of one pediatric crash carts (locked cart with pediatric emergency supplies). The CAH's failure to ensure emergency supplies were available to patients has the potential to cause harm and delay emergency care to patients.

Findings include:

- The CAH's Statement of Deficiency dated 7/9/15 cited, "...the CAH failed to ensure equipment and supplies commonly used in life-saving procedures were readily available to staff in one of three Emergency Department (ED) rooms, three of four crash carts (locked cart with emergency medications and supplies), and two of two Braselow bags (pediatric emergency kit) ..."

- The CAH's Plan of Correction received on 7/23/15 directed, "...A hospital wide process will be implemented to manage supply outdates and to make sure that there are no expired supplies in any area of the hospital ..."

The CAH's policy "Monitoring of Supplies with Expiration Dates" reviewed on 8/11/15 at 10:10am directed staff, "...Any outdated items shall be removed from the storage area of the unit and shall be immediately returned to the Materials Management Department..."
- Emergency Department observed on 8/10/15 between 1:20pm to 2:20pm revealed the following expired and unusable supplies:

Emergency Room #1:
1. One Purple Pediatric Emergency Kit containing two IV (intravenous) catheters, one IV kit, and one extension tubing with an expiration date of 6/2015
2. A bin containing 133 cardiac monitoring electrodes which lacked the date the electrodes would expire. Observation of an unopened bag of cardiac electrodes revealed an expiration date printed on the bag.

Emergency Room #2 bay A
1. Two 2x2 Gauze sponges expired 7/2015
2. Two 3x3 Gauze sponges expired 7/2015
3. One Hydrocolloid wound dressing (dressing with a gel forming material) expired 6/2015.
4. A bin containing 19 cardiac monitoring electrodes which lacked the date the electrodes would expire.
Emergency Room #2 bay B
1. Five blue top lab specimen tubes expired 7/2015.
2. A bin containing 72 cardiac monitoring electrodes which lacked the date the electrodes would expire.

Registered Nurse Staff C interviewed on 8/10/15 between 1:20pm and 2:20pm acknowledged the expired emergency room supplies and noted the cardiac monitoring electrodes had been removed from there package and the package contained information including an expiration date.

The CAH failed to ensure equipment and supplies commonly used in life-saving procedures were readily available and follow their Plan of Correction.

The Critical Access Hospital reported a total census of four acute patients and four swing bed patients. Based on observation, Statement of Deficiency review, policy review, and interview the hospital failed to provide for the safety of patients and or staff in one of three emergency rooms with portable oxygen tanks. This deficient practice has the potential to cause harm to patients and staff members.

Findings include:

- Review of the CAH's Statement of Deficiency dated 7/9/15 cited, "...The oxygen storage room observed on 7/7/15 at 12:25pm revealed two E oxygen tanks and seven D oxygen tanks sitting on the cement floor. The oxygen tanks failed to be secured in a cylinder stand or to a stationary object ..."


The CAH's Plan of Correction received on 7/23/15 directed, "...Additional bottle (oxygen bottle) racks were placed in the bottle room to accommodate additional cylinders ..."

- The CAH's policy "use of Flammables and Oxygen Safety" reviewed on 8/11/15 at 10:10am directed, "...To ensure a safe environment for the patient, staff and visitors ...Oxygen Cylinder storage should occur on secure carts or secured to a stationary object..."

- Emergency Room #2 observed on 8/10/15 at 2:10pm revealed one E oxygen tank sitting on the floor. The oxygen tank failed to be secured in a cylinder stand or to a stationary object.

Registered Nurse Staff C interviewed on 8/10/15 at 2:10pm in Emergency Room #2, acknowledged the unsecure oxygen tank.

The CAH failed to provide for the safety of patients and/or staff by securing an oxygen tank and failed to follow their Plan of Correction.

The Critical Access Hospital (CAH) reported a total current census of four acute patients and four swing bed patients. Based on observation, staff interview, and document review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices, which could contribute to healthcare acquired infections of patients and personnel. Observations included two of three Emergency Rooms. The CAH's failure to identify failures with infection control practices created the potential for healthcare acquired infections.

Findings include:

- Review of the CAH ' s Statement of Deficiency received on 7/9/2015 cited Yankauer suction handles (plastic tube to suction secretions from a person's mouth) open and ready for use.


The CAH's Plan of Correction received on 7/23/2015 directed, "...Single use items will not be opened and ready to use " just in case " . All single use items will remain unopened until needed for immediate use... "

- The CAH's policy for outdated supplies reviewed on 8/11/15 at 10:15 AM directed, " ...Opened but unused single use medical devices must be discarded and not left opened or connected for emergent usage..."

- Emergency department room one observed on 8/10/2015 at 1:30 PM revealed one single use sterile package of Telfa Adhesive Island dressing (a soft woven dressing used for open wounds) open and available for patient use in a blue storage bin located on the shelf.
- Emergency department room 2 area B observed on 8/10/2015 at 2:15 PM revealed the following opened single use sterile items: one yankauer suction handle and one suction tubing package open and lying on the counter ready for use.
Registered Nurse staff C interviewed on 8/10/2015 at 2:16 PM acknowledged the opened single use suction tubing, yankauer suction handle, and Telfa Adhesive Island dressing.

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to follow written policies for medical records storage (refer to C-0301), failed to ensure medical records contained a pertinent medical history and physical completed in a timely manner and ensure a complete medical record within thirty days (refer to C-0304), and failed to safeguard confidential patient information from possible destruction or unauthorized use (refer to C-0308).

The cumulative effect of the systematic failure to follow written policies for medical records storage, failure to ensure medical records contained a pertinent medical history and physical completed in a timely manner and ensure a complete medical record within thirty days, and failure to safeguard confidential patient information from possible destruction or unauthorized use resulted in the CAH's inability to provide care in a safe and effective manner.

The Critical Access Hospital (CAH) reported a total current census of four acute patients and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to follow written policies for medical records stored in three of four medical record storage areas and failed to follow their Plan of Correction. This practice has the potential to affect the patient's records in three of four medical record storage areas.

Findings include:

- Review of the CAH's Statement of Deficiency received on 7/9/2015 cited "...banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor ..." and "The CAH failed to safeguard confidential patient information from possible destruction and/or unauthorized use."



The CAH's Plan of Correction received on 7/23/2015 directed, "...The remaining paper medical records since implementing an electronic medical record will be stored in the proper manner and safeguard in the proper manner..."

- The CAH's policy "Secure Filing of Medical Records" reviewed on 8/11/15 at 7:30 AM directed, "...Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals ...Medical records will be maintained in a manner that shelving will be secure to house and protect the records ...The Health Information Management Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals ..."

- Medical Records storage room located across from the x-ray department observed on 8/10/2015 at 11:00 AM revealed an unattended and unsecured room with shelving on two walls filled with multiple file folders containing patients' radiology studies.

Medical Records staff F interviewed on 8/10/2015 at 1:00 PM acknowledged the unattended and unsecured medical records storage room. Staff F revealed they had not provided hospital staff education on medical record storage requirements.

- The Medical Records storage room in the old whirlpool room observed on 8/10/15 at 12:30 PM revealed a room with a whirlpool, double sink and wall water supply. The storage room contained two Banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor.

Medical Records Staff E interviewed on 8/10/15 at 12:35 PM acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for flooding. The CAH failed to assure protection of medical records from destruction.

- The Medical Records office observed on 8/10/15 at 12:20 PM revealed an open and unattended office immediately after stepping off the elevator containing multiple shelfs and Bankers boxes containing medical records. Seventeen Bankers boxes were located directly on the floor with the potential for flooding. A sign taped to the door read, "We are currently out of the office for assistance please go next door."
Medical Records staff E interviewed 8/10/2015 at 12:25 PM acknowledged the medical records room was open and unattended leaving confidential patient information unprotected. Staff E revealed there are approximately 50,000- 60,000 medical records on the shelves and 17 Bankers boxes placed directly on the floor. Staff E acknowledged they were unable to see or hear if anyone entered the medical records room from the neighboring office.

The Critical Access Hospital (CAH) reported a total census of four acute patients and four swing bed patients. Based on medical record review, Statement of Deficiency review, policy review, and staff interview the CAH failed to ensure a complete medical record within thirty days for two of two closed surgical medical records reviewed (Patient #'s 6 and 7) The CAH's failure to ensure patients' medical history and physical are competed in a timely manner and complete a closed medical record timely has the potential for poor patient outcomes.

Findings include:

- The CAH's Statement of Deficiency dated 7/9/15 cited, "...the CAH failed to ensure a complete medical record within thirty days for two of twenty seven closed medical records reviewed ..."

- The CAH's policy "Completion of Medical Records" reviewed on 8/10/15 at 11:30pm directed, "...In accordance with Kansas Hospital Regulation, records of discharged patients are completed within 30 days of dismissal..."

- Patient #6's surgical medical record reviewed on 8/10/15 revealed an admission date of 7/10/15 for a surgical procedure and discharged on 7/10/15. Patient #6's operative report record lacked a signature by the physician (31 days after discharge).

Electronic Medical Records Director Staff A interviewed 8/10/15 at 4:00pm acknowledged patient #6's operative report lacked evidence of physician's signature.

- Patient #7's surgical medical record reviewed on 8/11/15 revealed an admission date of 7/10/15 for a surgical procedure and discharged on 7/10/15. Patient #7's operative report record lacked a signature by the physician (31 days after discharge).

Electronic Medical Records Director Staff A interviewed 8/11/15 at 8:35am acknowledged patient #7's operative report lacked evidence of physician's signature.

The CAH failed to ensure complete surgical medical records within thirty days.

The Critical Access Hospital (CAH) reported a total current census of four acute patients and four swing bed patients. Based on observation, staff interview, and policy review the CAH failed to safeguard confidential patient information from possible destruction or unauthorized use. This practice has the potential to affect the patient's records in three of three medical record storage areas.

Findings include:


- Review of the CAH's Statement of Deficiency received on 7/9/2015 cited "...banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor ..."


The CAH's Plan of Correction received on 7/23/2015 directed, "...The remaining paper medical records since implementing an electronic medical record will be stored in the proper manner and safeguard in the proper manner..."

- The CAH's policy "Secure Filing of Medical Records" reviewed on 8/11/15 at 7:30 AM directed, "...Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals ...Medical records will be maintained in a manner that shelving will be secure to house and protect the records ...The Health Information Management Department is responsible for safeguarding both the record and its informational content against loss, defacement and tampering. They are also responsible to safeguard the medical record against use by unauthorized individuals ..."

- Medical Records storage room located across from the x-ray department observed on 8/10/2015 at 11:00 AM revealed an unattended and unsecured room with shelving on two walls filled with multiple file folders containing patient radiology studies.

Medical Records staff F interviewed on 8/10/2015 at 1:00 PM acknowledged the unattended and unsecured medical records storage room. Staff F revealed they had not provided hospital staff education on medical record storage requirements.

- The Medical Records storage room in the old whirlpool room observed on 8/10/15 at 12:30 PM revealed a room with a whirlpool, double sink and wall water supply. The storage room contained two Banker boxes (cardboard boxes used to store medical records) with patients' medical records placed directly on the floor.

Medical Records Staff E interviewed on 8/10/15 at 12:35 PM acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for flooding. The CAH failed to assure protection of medical records from destruction.

- The Medical Records office observed on 8/10/15 at 12:20 PM revealed an open and unattended office immediately after stepping off the elevator containing multiple shelves and Bankers boxes containing medical records. Seventeen Bankers boxes were located directly on the floor with the potential for flooding. A sign taped to the door read, "We are currently out of the office for assistance please go next door."
Medical Records staff E interviewed 8/10/2015 at 12:25 PM acknowledged the medical records room was open and unattended leaving confidential patient information unprotected. Staff E revealed there are approximately 50,000- 60,000 medical records on the shelves and 17 Bankers boxes placed directly on the floor. Staff E acknowledged they were unable to see or hear if anyone entered the medical records room from the neighboring office.