HospitalInspections.org

Based on observation, interview and review of the Critical Access Hospital (CAH) policies and procedures it was determined that the CAH failed to ensure that the provision of services for perioperative practice are maintained related to proper surgical attire during an operative procedure.

This is evidenced by:

The CAH SURGICAL SERVICES policy and procedure titled "Attire in the Operating Room" revealed;

"Purpose:
To assure proper surgical attire in the operating room by all personnel, including staff and providers.

General:
... 3. Eye protection is worn whenever contact with blood, body fluids or other potentially infectious material is anticipated.."

Observation during tour of the CAH Operating Room on 5/11/16 with Staff D (R.N., Director of Surgical Services) revealed at approximately 9:50 a.m. in Operating Room #1 Staff E (Surgeon) had donned a sterile gown and gloves to perform a scheduled orthopedic surgical procedure (Excision Right Prepatella Bursa). Further observation at this time revealed that Staff E had no protective eyewear in place.

During interview with Staff D at the time of this observation, Staff D did verbally confirm that personal protective equipment (PPE) to include protective eyewear is required in the restricted areas of the surgical suite. This includes eyewear during surgical procedures as indicated in the CAH policy and procedure listed above, "whenever contact with blood, body fluids or other potentially infectious material is anticipated."

Staff D did verbalize that AORN (Association of Operating Room Nurses) standards of practice require protective eyewear as part of the perioperative practice during operative procedures and verbally confirmed that Staff E had no protective eyewear in place at the time of this observation to perform the scheduled orthopedic surgical procedure.

Based on observation and interview the Critical Access Hospital (CAH) failed to store medication in a safe manner.

Findings include:

During tour of the Medical Surgical Unit with Staff A (Unit Manager), this surveyor noted that the medication storage room door was left in the open position and there were no nursing staff present in this room thus, allowing full access to anyone on the unit to this room. Upon entering the medication room, it was noted that a medication bottle labeled as fiber pills was left out on the computer. There were also bins of medications on a rack in this medication room.

During interview, Staff A stated that the bottle of fiber pills was a medication that a current patient brought in with them and these type of medications are placed in a bin that is specific to that patient only. Staff A stated that there are no narcotic or controlled medications kept in these bins. Staff A also stated that the medication room door is to be closed when staff are not present in the medication room.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure the CAH's off site medical records are protected from potential loss (fire).

Findings include:

The CAH stores medical records at an offsite 1 story building with a full basement near the hospital. During a tour of this building on 5/12/16 at approximately 12:45 it was noted that neither the main level nor the basement is sprinklered. During interview on 5/12/16 at approximately 1 p.m. with Staff B (Senior Director, Administrative Services and Revenue Cycle Services) Staff B verbally confirmed that the building is not sprinklered. Currently, there are approximately 600 boxes of medical records that are in the basement of this building waiting to be scanned into the CAH's computer system according to Staff B during above noted interview.

Based on record review and interview it was determined that the Critical Access Hospital failed to maintain complete patient medical records. (Patient identifiers are #1 and #2.)

Findings include:
Patients #1 and #2

Record review on 5/11/16 of four discharge patient records revealed two discharge patient's (#1 and #2) received the incorrect QIO (Quality Improvement Organization) information.

During interview with Staff C (Patient Access Director) on 5/11/16 at approximately 2:00 p.m., Staff C verbally confirmed that Staff C was unaware that the QIO in the above charts was no longer the QIO that had the contract for the hospital.