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Based on observations, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations and during emergencies for three of six Emergency Crash Carts (one Inpatient unit, one ED and one anesthesia cart) and for one of one CT scan (computerized tomography-X-ray taken from different angles giving detailed information) room. This deficient practice or the failure of the facility to dispose the expired supplies places all patients at risk for receiving ineffective supplies.


Findings include:


- Inpatient Nursing Station Emergency Crash Cart observed on 4/25/2017 at 9:00 PM revealed one King LTSD Kit Size 5 Trousse (disposal airway device that provides superior patient ventilation) with expiration date of 7/2016 in the respiratory care drawer.

RN Staff A interviewed on 4/25/2017 at 9:00 AM acknowledged the King LTSD kit was expired. Staff A stated Respiratory Therapy is responsible for watching their own outdates. Staff A stated she will go to the Respiratory Therapy office and show them their expired supply.

- CT scan room supply cabinet observed on 4/25/2017 at 10:45 AM revealed one Biopsy Needle 18guage x 10 centimeters with expiration date of 6/28/2016.

Manager of Radiology Staff C interviewed on 4/25/2017 at 10:45 AM acknowledged the Biopsy Needle was expired and should have been disposed.

- ED Nursing Office Rapid Response Cart observed on 4/24/2017 at 1:00 pm revealed the following opened packages and outdated medical supplies:

1-34 Fr., 8.5mm PVC Nasopharyngeal airway (tube placed in the nose and wind pipe)

1- 14 Fr Sheathed Stylet/Endotracheal (guide wire used for inserting a tube into the airway)

1-Slick Stylet Disposable Endotracheal tube, outdated 3/2017

ED Staff RN acknowledged the open and outdated supplies.

- PACU emergency crash cart observed on 4/25/2017 at 7:30 am revealed the following outdated medical supplies:

1-Lab Tube, outdated 9/2016

5-Lab Tubes, outdated 7/2016

4-Lab Tubes, outdated 3/2017

3-Insyte 20 G 1 ½" IV catheter, outdated 1/2017

1- Normal Saline 10cc syringe, outdated 2/2017

Surgical RN Staff N acknowledged the outdated supplies and disposed of them.

- Policy reviewed on 4/25/2017 revealed the CAH failed to ensure to have a policy to have staff dispose of their expired supplies.

Based on interview and policy review, the critical access hospital, (CAH) failed to credential or grant privileges to all providers writing orders for patient care. Failure to perform credentialing on all providers can lead to orders written by non-licensed personal resulting in the provision of unsafe care to patients by hospital staff following the orders.


Findings include:


- Interview of Director of Specialty Clinic Staff # L on 4/24/2017 at 3:00 pm confirmed that not all of the patients receiving care in the Specialty Clinic have a staff physician who oversees their care and some patients do not have a local physician. The ordering physician might not be credentialed through the hospital or even an in-state physician. Patients receiving care through the Specialty Clinic come from Kansas, Nebraska, and Colorado. Director Staff #L confirmed if an emergency or adverse event occurs with a patient in the Specialty Clinic and the patient does not have a physician on staff at the hospital, the patient is taken to the emergency department for assessment and treatment.

No policy was available regarding orders provided by non-credentialed providers.

Review of policy "Verification of Ordering Practitioner's License" directed "...When a patient presents an order from a practitioner that is not recorded in the CPSI system, the admission department enters the practitioner with their name, address, and National Provider Identification (NPU) number into the CPSI system and forwards to the Health Information Credentialing Clerk... ...The Credentialing Clerk searches via internet Kansas Doc Finder or Kansas Board of Healing Arts for practitioners licensed in the state of Kansas... ...when the license is located, the activation and expiration dates are verified ... ...Physicians and mid-level practitioners who are not credentialed in any other category and are ordering ancillary and diagnostic tests at CMC will be assigned to the ordering privileges category following the verification process..."


The Kansas Board of Healing Arts Under Article 26 states the following, "..."Valid order" means an order by an out of state practitioner for a diagnostic professional service or therapeutic professional service that is transmitted orally, electronically, or in writing, if all of the following conditions are met:

1. The order is within the lawful scope of authority of the out-of-state practitioner.

2. The order may be lawfully ordered or provided by a licensee in this state who practices the same branch of the healing arts as that of the out-of-state practitioner.

3. The order is issued by an out-of-state practitioner who is not any of the following:

A. A licensee whose license is suspended;

B. an individual who previously was a licensee whose license is revoked under K.S.A. 65-2836 and amendments thereto; or

C. a licensee whose license has a limitation by the board that prohibits the order.

Based on observation, staff interview and lack of policy for review the Critical Access Hospital (CAH) failed to ensure outdated, unusable medications were removed and made unavailable for patient use in two of six Emergency Crash Carts (Emergency Cesearean Section and Pediatric Emergency Crash Carts) and one supply room. The CAH failed to assure medication drawn up by a professional staff was administered by that staff person for one of one observations. This deficient practice to ensure that outdated medications are unavailable for patient use placed all patients at risk for receiving ineffective medications.



Findings Include:


- Observation in the Obstetric on 4/24/17 at 3:05pm revealed the following:

In a supply room an emergency cesarean section emergency kit with two 20 milliliter (ml) vials of xylocaine (a medication used to numb the skin) with an expiration date of 3/17 and a bottle of povidone iodine (a solution to disinfect the skin) with an expiration date of 3/17.

In a supply room an emergency hemorrhage (excessive bleeding) kits with one 500ml intravenous (IV) bag of sodium chloride (a salt solution) with an expiration date of 4/1/17.

In a pediatric emergency crash cart a kit with one opened 50ml vial of xylocaine with an open date of 3/8/17, and one adult CO2 detector (a breathing apparatus that measures the carbon dioxide the patient exhales) with an expiration date of 12/20/16.

Staff X Registered Nurse (RN), interviewed on 4/24/17 at 3:30pm acknowledged that the medications had expired according to the manufacturer's expiration dates. Staff X explained once the vial is open and a date when opened on it, it needs to be discarded 30 days after it was opened.

- Observation in the PACU (Post Anesthesia Care Unit) on 4/25/17 at 8:10am revealed an Intravenous (IV) tray with supplies on it to start IVs with a ten ml syringe of Sodium Chloride (a salt solution) with an expiration date of 2/2017.

Staff N, RN interviewed on 4/25/17 at 8:10am acknowledged that the 10ml syringe of Sodium Chloride was outdated and available for patient use.

Staff F, RN administration, and Staff I, RN administration interviewed on 4/25/17 at 4:30pm explained the CAH does not have a policy/procedure regarding the discarding of expired medications.

Based on record review, interview, and policy review, the critical access hospital (CAH) failed to document a history and physical, assessment, and medication review of 1 of 2 (Patient #15) medical records reviewed. Failure to perform an assessment and review medications with each outpatient treatment performed and failure to have a current history and physical available put hospital staff at risk of providing unsafe care and patients at risk of receiving medications and treatments that are contraindicated.


Findings include:


- Review of Patient #15's closed medical record on 4/26/2017 at 2:30 pm revealed the patient, 54 years old, diagnosed with chronic inflammatory demyelinating neuropathy (CIDP) (an acquired immune disease in which the covering of the nerves are damaged) receives IV Carimune (immunoglobulin replacement) every four weeks. The medical record lacked evidence of a history and physical, assessment, medication review, nursing care plan, and evidence of patient education.


Interview with Director of Specialty Clinic RN Staff L acknowledged the staff do not perform an assessment or medication review with each outpatient and that the history and physical are not on the chart, nor is a nursing care plan.


The CAH was unable to provide a Specialty Clinic documentation policy.

Based on documentation, observation, staff interview, AORN (Association of Operating Room Nurses) guidelines, and policy review, the Critical Access Hospital (CAH) failed to ensure to follow their policy and properly monitor the OR (Operating Room) temperature and humidity for two of two OR suites, for one of one preoperative area, one of one PACU (Post Anesthesia Care Unit) and one of one Sterile central supply room. The CAH failed to provide a physical environment for the cleaning and decontamination of surgical instruments separate from the clean area used for surgical instrument packaging and sterilization. The Critical Access Hospital failed to assure operating room staff covered head hair, including side burns and the nape of the neck for five of five observations in the operating suite area and failed to provide a physical environment for the cleaning and decontamination of endoscopes separate from the clean area used for the clean endoscopes for one of one reprocessing room. Failure to monitor OR temperature and humidity has the potential of microbial growth, increase risk of infections, promoting patient discomfort and cross contamination of sterile supplies and equipment. Failure to provide physical separation can result in cross contamination of the endoscopes both through aerosolization (dispersing particles into the air) and direct contamination of particle displacement during endoscope cleaning.

Findings Include:

- Documentation review of Operating Room #1 temperature/humidity log on 4/26/2017 at 12:00 PM revealed the CAH failed to ensure the temperatures and humidity's were maintained and functioning properly within the acceptable standard of the American Society for Heating Refrigerating, and Air Conditioning Engineers (ASHRAE). The following were out of range:
January 2017- Temperature 21 days out of 22 days; Humidity 11 days out of 22 days
February 2017- Temperature 18 days out of 18 days; Humidity 9 days out of 18 days
March 2017- Temperature 23 days out of 23 days; Humidity 14 days out of 23 days
April 2017- Temperature 18 days out of 18 days; Humidity 3 days out of 18 days

- Documentation review of the Operating Room #2 temperature/humidity log on 4/26/2017 at 12:00 PM revealed the CAH failed to ensure the temperatures and humidity's were maintained and functioning properly within the acceptable standard of the American Society for Heating Refrigerating, and Air Conditioning Engineers (ASHRAE).The following were out of range:
January 2017- Temperature 17 days out of 17 days; Humidity 11 days out of 17 days
February 2017- Temperature 20 days out of 20 days; Humidity 12 days out of 18 days
March 2017- Temperature 24 days out of 24 days; Humidity 12 days out of 24 days
April 2017- Temperature 18 days out of 18 days; Humidity 3 days out of 18 days

- Documentation review of the Preoperative area, PACU and Sterile Central Supply room on 4/26/2017 at 12:15 PM revealed the CAH failed to monitor and maintain the temperatures and humidity's of those areas.

Surgery Manager Staff D interviewed on 4/26/2017 at 12:15 PM acknowledged the maintenance of the temperature and humidity in the ORs had not been maintained properly. Staff D stated they did not realize they were out of range. Staff D mentioned they looked at the Temperature/Humidity log sheets to make sure the Technicians did record the temperature and humidity every day but didn't focus on if they were in range or not. Staff D stated "it is my responsibility to make sure the temperatures and humidity's are in range and report it." Staff D stated we have never monitored the temperature and humidity in the Preoperative, PACU and Sterile Central Supply room, did not realize we had too.

Plant Operation/Environment Staff Z interviewed on 4//26/2017 at 1:45 PM stated they have not heard that the OR temperatures and humidity's were out of range. Staff Z stated the OR staff reports to us if any there are any problems.

- Addendum D of the ASHRAE standard requires RH in ORs to be maintained between 20-60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute.

- Policy titled "Infection Prevention Guidelines for Surgical Services Department" reviewed on 4/26/2017 at 12:15 PM directed the CAH " ...Humidity shall be maintained at 20-60% within the Surgical Suite. Temperature in the Surgical Suite shall be maintained at 68-75 degrees Fahrenheit. Humidity and Temperature Log shall be maintained by the Surgical Services Manager or designated Surgical Technician ....If the temperature and/or humidity are outside the above stated parameters, Plant Operations and the surgeon (s) shall be notified for possible required intervention.

- Observation of the surgical decontamination room on 4/25/2017 at 12:00 pm revealed a small room with a specimen hopper (device used to flush contaminated liquids and solids) surrounded by a plastic wall on 3 sides, a double sink, a short counter with an ultrasound machine on the counter, and a sterilizer next to the ultrasound lining one wall of the room. The wall directly opposite contained a cart with dirty instruments and a trash hamper. At the end of the decontamination room was a door into the clean instrument room where instruments were wrapped for processing. A second sterilizer was located in this room. Scrub Tech Staff Q was observed scrubbing instruments in the sink. Scrub Tech Staff S entered the room and washed his/her hands in the second sink where the instruments were rinsed, donned PPE and began assisting with the instrument decontamination.

Scrub Tech Staff Q stated the hopper is used only if there is contaminated solutions that need to be flushed. S/he acknowledged that the room was small and would get very crowded trying to clean all of the instruments and keeping them separated. S/he confirmed the number of procedures performed had outgrown the area for processing.
Surgical Supervisor RN Staff D confirmed surgical instrument cleaning and decontamination should be physically separated from the clean area and that s/he had been receiving information for changes with plans to renovate the area by the end of 2017.

Guideline for Disinfection and Sterilization in Healthcare Facilities, published by the CDC in 2008 recommends " ...Physical Facilities. The central processing area(s) ideally should be divided into at least three areas: decontamination, packaging, and sterilization and storage. Physical barriers should separate the decontamination area from the other sections to contain contamination on used items ... ... The recommended airflow pattern should contain contaminates within the decontamination area and minimize the flow of contaminates to the clean areas. The American Institute of Architects 959 recommends negative pressure and no fewer than six air exchanges per hour in the decontamination area (AAMI recommends 10 air changes per hour) and 10 air changes per hour with positive pressure in the sterilizer equipment room. The packaging area is for inspecting, assembling, and packaging clean, but not sterile, material. The sterile storage area should be a limited access area with a controlled temperature (may be as high as 75oF) and relative humidity (30-60% in all works areas except sterile storage, where the relative humidity should not exceed 70%) ..."

- Observations in the operating room suite on 4/25/17 at 8:00am revealed staff AA, RN (Registered Nurse) wearing a bouffant head cover with exposed hair around the ears and nape of neck.

- Observation in the operating room suite on 4/25/17 at 8:00am revealed staff O, physician wearing a bouffant head cover with exposed hair around the ears, side burns, and nape of neck.

- Observation in the operating room suite on 4/25/17 at 8:00am revealed staff BB, CRNA (Certified Registered Nurse Anesthetist) wearing a bouffant head cover with exposed hair around the ears and nape of neck.

- Observation in the operating room suite on 4/25/17 at 8:10am revealed staff Q, RN wearing a bouffant head cover with exposed hair around the ears and nape of neck.

- Observation in the PACU (Post Anesthesia Care Unit) on 4/25/17 at 8:20am staff N, RN wearing a bouffant head cover with exposed hair around the ears and nape of neck.

Staff D, RN, Surgical Supervisor interviewed on 4/25/17 at 11:50am explained that the head covers the operating room staff use is to cover all hair completely.

- The CAH's policy/procedure for surgical services titled, "Dress Code" reviewed on 4/26/17 directed, " ...All head and facial hair shall be covered while in the operating room ...nape of neck, and all hair must be contained in the head cover ..."

- The AORN guidelines titled, "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings, 2013 Edition" reviewed on 4/27/17 directed, " ...under Recommendation IV, All personnel should cover head and facial hair, including side-burns and the nape of the neck, when in the semi restricted and restricted areas ..."
- Observation of the reprocessing room (a room where the endoscopes are cleaned and disinfected) on 4/25/17 at 10:15am revealed a small room with a specimen hopper (device used to flush contaminated liquids and solids) surrounded by a plastic wall on three sides, a double sink, a short counter with a "Steris" machine (a device used to disinfect the endoscopes), which put the clean endoscopes next to the sinks that are used to clean the scopes, and at the end of the short counter was a metal cart that housed a basin with "Cidex (a high level disinfectant) used to disinfect some of the parts of the endoscopes that are not put in the "Steris" machine for disinfection. Next to the basin of "Cidex" was a tall cabinet that housed the cleaned endoscopes. The wall directly opposite of the hopper, sinks, and "Steris" machine contained two carts with supplies on them to clean the endoscopes.

Staff D, RN Surgical Supervisor interviewed on 4/25/17 at 11:50am confirmed the endoscope cleaning and decontamination area should be physically separated from the clean area.

- AORN guidelines titled, "AORN Perioperative Standards and Recommended Practices for Inpatient and Ambulatory settings, 2011 Edition reviewed on 4/26/17 directed, " ...the decontamination area should be physically separate from clean areas and include a door ..."

Based on medical record review and policy review the critical access hospital (CAH) failed to perform a pre-anesthesia evaluation, patient condition review, and post anesthesia follow-up in 1 (Patient #14) of 2 surgical medical records reviewed. Failure to perform pre and post anesthesia evaluation places surgical patients at risk of failure of the medical staff to anticipate potential complications associated with anesthesia.


Findings include:


- Medical record # 14 reviewed 4/26/2017 at 1:00 pm revealed anesthesia was provided by CRNA Staff Y. The medical record lacked documentation of a pre-anesthesia evaluation, lacked evidence of patients condition prior to surgery, and lacked evidence of post anesthesia follow up.


Policy "Organization and Responsibilities of Anesthesia Services" directs "...The Anesthesia Provider must perform a preoperative evaluation of the patients scheduled for surgery. This includes a review of that patient ' s chart including consultations, history and physical, lab, EKG, and radiology; and to determine the physical status of the patient according to the classifications stated above... ...Documentation must include date, time and signature of anesthesia provider... ...Pre anesthesia note should reflect the pre anesthesia assessment, plan of anesthesia care and a discussion with the patient and family regarding anesthesia complications risks alternatives and benefits... ...The post anesthesia record shall be completed by the Anesthesia Provider immediately in the postoperative care area with the following information properly documented, dated, and time."


Policy "Post-Operative Care" directs "...On admission to the Post Anesthesia Care Unit the anesthesia provider and the Post Anesthesia Care Unit nurse should jointly evaluate the patient and assign an initial score... ...Patients who's recovery scores are less than 9 can only be discharged by order of the anesthesia provider."