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I. Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscope procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The hospital's administrative staff identified surgical services staff performed an average of 20 endoscopic procedures per month during the fiscal year from July 2022 to May 2023.

Findings include:

1. Observations during a tour of the surgery department on 5/31/2023 at approximately 08:10 AM in review of the operating room procedures with Certified Surgical Technician A revealed 1 of 1 bottle ICUMed 1000 mL bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions indicated in part... "Sterile Water for Irrigation, USP contains no bacteriostat antimicrobial agent or added buffer and is intended for use only as a single-dose or short procedure irrigation ... unused portion should be discarded." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

3. During an interview at the time of the tour, the Supervisor of Surgical Services stated the surgery staff opened the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty. The Surgical Service Manager verified with the Olympus representative that the sterile water for irrigation should be removed after each case. The Surgical Service Manager acknowledged the manufacturer's directions for the ICUMed 1000 mL bottles of sterile water for irrigation did not support using the bottles of sterile water for irrigation for more than one patient.

II. Based on observation, document review and staff interview the Critical Access Hospital's (CAH) Staff failed to follow the manufacturer's instructions for the StatStrip Glucose Monitoring System when it failed to label a newly opened bottle of glucose control solution with the opened date on the label. Failure to follow the StatStrip Glucose Monitoring System manufacturer's instructions for use may result in inaccurate blood glucose readings. The CAH reported the Medical Surgical Unit performed approximately 966 blood glucose checks per month.

Findings include:

1) Observation on 5/30/2023 during a tour of the Medical Surgical Unit revealed two separate identical StatStrip Glucose Monitoring Systems in their respective cases. Each case contained one bottle of Control 1 and one bottle of Control 2. Each of these 4 control bottles had an expiration date of 6/2/24. Each of the 4 control vials were not labeled with the date they were opened.

2) Observation on 5/30/2023 at 11:30 AM while on tour in the Emergency Department revealed, StatStrip Glucose Monitoring System Control bottles 1 and Control bottle 2 were opened and labeled with an expiration date of 10/2022.

3) Review of the StatStrip manufacture's pamphlet, revealed in part, "The expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable when stored as indicated for up to 6 months or until the expiration date, whichever comes first."

4) Review of Policy "Point of Care- Nova StatStrip Glucometer" revealed in part, "StatStrip Glucose Strips: Open expiration six months, or until expiration date printed on label. Date with expiration date when opening bottle. StatStrip Glucose Control Solutions Level 1 and 3. Open expiration three months or until expiration date printed on label. Date with expiration date when opening bottle."

5) During an interview on 5/30/23 during the tours on the Medical Surgical and the Emergency Department with the Vice President of Patient Care Services acknowledged these vials were expired or not labeled per CAH's policy.

Based on staff interviews and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff notified the patients' physician following the discovery of a medication error for 1 of 10 medication errors reviewed (Patient #6) and failed to document the date and time the nursing staff notified the physician for 5 of 10 medication errors reviewed (Patient #3, Patient #4, Patient #5, Patient #7, and Patient #8). Failure to notify the physician of medication errors could potentially result in the physician lacking knowledge of the medication error and failing to potentially modify the patient's treatment plan, potentially resulting in a life-threatening complication. The CAH administrative staff reported a census of 8 patients on entrance.

Findings Include:

1. Review of the CAH policy "Medication Management: Administration and Verification," last revised 6/2022, revealed in part, " ...A medication event is defined as an error in prescribing, transcribing, dispensing, and administration ... Document if physician notified ..."

2. Review of medication errors on 5/31/23 revealed the following:

a. On 5/24/23 at 2:29 PM, the nursing staff discovered they failed to administer a dose of Magnesium Oxide (a medication used to treat low magnesium levels) to Patient #3. The medication error record lacked documentation of the date or time the nursing staff notified Patient #3's physician of the medication error.

b. On 5/15/23 at 8:34 AM, the nursing staff discovered they failed to administer two doses of clotrimazole cream (topical cream used to treat fungus infections on the skin) to Patient #4. The medication error record lacked documentation of the date or time the nursing staff notified Patient #4's physician of the medication error.

c. On 2/27/23 at 4:49 PM, the nursing staff discovered they failed to administer a dose of Fosfomycin (Antibiotic used to treat infections such as urinary tract infections) to Patient #5. The medication error record lacked documentation of the date or time the nursing staff notified Patient #5's physician of the medication error.

d. On 2/13/23 at 7:45 AM, the nursing staff discovered they failed to administer a dose of Dronabinol (a medication used to treat nausea and vomiting) to Patient #6. The medication error lacked documentation the nursing staff notified Patient #6's physician of the medication error.

e. On 11/10/22 at 6:09 PM, the nursing staff discovered they administered the incorrect medication of Heparin (an anticoagulant used to decrease the clotting ability of the blood and help prevent harmful clots from forming in the blood vessels) to Patient #7. The medication error record lacked documentation of the date or time the nursing staff notified Patient #7's physician of the medication error.

f. On 10/16/22 at 4:26 PM, the nursing staff discovered they failed to administer a dose of simvastatin (a medication used to lower cholesterol and triglyceride levels) to Patient #8. The medication error record lacked documentation of the date or time the nursing staff notified Patient #8's physician of the medication error.

3. During an interview on 6/1/23 at 11:05 AM, the Vice President (VP) of Patient Care Services acknowledged the medical records lacked documentation the nursing staff notified the physician when they made the medication error on Patient #6 and the medical records lacked documentation of the date or time the nursing staff notified the physician of the medication errors for Patient #3, Patient #4, Patient #5, Patient #7, and Patient #8.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 2 of 5 reviewed closed (3) and open (2) swing bed patients (Patient #1 and Patient #2). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehabilitation services appropriate to their medical condition. The CAH's administrative staff identified an average of 11 swing bed admissions in Fiscal Year 2022.

Findings include:

1. Review of the CAH's policy "Provision of Services," last reviewed 10/2022, revealed in part, " ...Specialized rehabilitation services must be provided under the written order of a physician and provided by qualified personnel."

2. Review of Patient #1's closed medical record revealed the CAH staff admitted Patient #1 for swing bed level of care on 5/15/23. Advanced Registered Nurse Practitioner B (ARNP) (a staff member with advanced training to diagnose and treat patients) wrote an order on 5/15/23 at 10:43 AM for Physical Therapy, Occupational Therapy, and Speech Therapy to evaluate and treat Patient #1.

3. Review of Patient #2's open medical record revealed the CAH staff admitted Patient #2 for swing bed level of care on 5/24/23. ARNP C wrote an order on 5/24/23 at 4:50 PM for Physical Therapy, and Occupational Therapy to evaluate and treat Patient #2.

4. During an interview on 6/1/23 at 11:05 AM, the Vice President (VP) of Patient Care Services acknowledged a physician did not write the therapy orders for Patient #1 and Patient #2. VP of Patient Care Services also acknowledged the CAH's policy, which stated "specialized rehabilitation services must be provided under the written order of a physician."