HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure hypodermic needles and intravenous supplies were securely stored in 3 of 6 emergency department bays.

Findings include:

On 9/22/14, during initial tour of the emergency department (ED) from 2:30 p.m. until 4:00 p.m. unlocked emergency supplies were observed in 3 of 6 ED bays. The supplies included many different sizes and styles of hypodermic needles. Registered nurse (RN)-A who managed the ED was interviewed during this time and confirmed the hypodermic needles were accessible to patients, staff and the public and should have been securely stored.

A CAH policy related to safe storage of medical equipment was requested from the director of nursing on 9/24/14, at 4:10 p.m. however, a policy was not provided.

Based on interview and document review the critical access hospital (CAH) failed to obtain a contract for a fuel provider in the event of a disruption of heating services. This had the potential to affect all patients serviced by the CAH.

Findings include:

During an interview on 9/22/2014, at 2:30 p.m. the director of the physical plant stated the CAH utilized natural gas as the main source for heating with fuel oil as a secondary source. Currently, the CAH had a back up fuel oil source that would be adequate for four days in the event of a disruption of natural gas service. However, the CAH failed to obtain a contract with a fuel oil company which could guarantee the delivery and the amount of fuel oil needed in the event of an emergency.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the Governing Board assumed responsibility for implementation of medical staff by-laws including ensuring medical staff held medical staff meetings and ensured a quorum was present when voting according to the medical staff by-laws. These deficient practices had the potential to affect all current CAH patients (11) and future patients of the CAH.

Findings include:

Review of the Medical Staff By-Laws/ Rules and Regulations (undated) revealed the following: "3. C. ELECTION AND TERMS OF OFFICE The officers of the Medical Staff shall be elected at the annual meeting of the staff and shall hold office until the next annual meeting or until a successor is elected...4. A. GENERAL All necessary committee functions will ordinarily be performed by designated Medical Staff as a whole, but an individual staff member may decline service in a specific committee area. Appointment of these committees shall be made by the incoming Chief-of-Staff at the annual Medical Staff meeting. A committee may be added or deleted as need arises. The Medical Staff, constituting as a committee of the whole, will perform the following functions: a. Medical Records b. Blood Transfusion Review c. Tissue Review d. Credentialing e. Utilization Review f. Performance Improvement g. Pharmacy and Therapeutics h. Policies and Procedures...5.A.2. Regular Meetings: The primary objectives of the Medical Staff meetings is improvement in the care and treatment of patients in the Hospital. Monthly meetings of the Medical Staff shall be held on a regular basis. The various functions of the staff shall be reviewed at each meeting.


Review of the CAH Governing Board Meeting Minutes dated 10/25/12, revealed that the Governing Board approved a change in how the Medical Staff conducted their Medical Staff Meetings. The Medical Staff meetings changed from a group gathering and discussion, to an electronic "Virtual" meeting via a workspace in the CAH computer system over a 48 hour period of time.

Review of the Medical Staff meeting minutes from 10/25/12-9/25/14, revealed the Medical Staff had not been coming together to have a monthly Medical Staff meeting at a set time to engage in meaningful discussion related to medical records, blood transfusion review, tissue review, credentialing, utilization review, performance improvement, pharmacy and therapeutics, and policies and procedures. When reviewed the Medical Staff meeting minutes reflected that a "Virtual" meeting occurred every other month and had an average attendance of 4-5 Medical Staff Members out of approximately 37 Medical Staff Members.

The Chief Executive Officer (CEO) was interviewed on 9/25/14, at 10:55 a.m. and stated the Medical Staff meeting format had changed a few years ago to a "Virtual" meeting as an attempt to increase Medical Staff participation. The CEO stated that prior to using the "Virtual" meeting format the Medical Staff attendance at the Medical Staff meetings was "non-existent." The CEO confirmed the Medical Staff meetings were not held monthly according to the Medical Staff By-laws, the Medical Staff By-Laws had not been changed to reflect the "Virtual" Medical Staff meeting format and there was no way to tell in the "Virtual" Medical Staff meeting if there was a quorum for voting purposes.

Based on interview and document review, the critical access hospital (CAH) did not ensure the following patient care services had developed a quality assurance (QA) process which was integrated into the CAH's QA program: cardiac rehabilitation; respiratory/sleep study department and the nutrition services. This had the potential to affect all current inpatients of the CAH (11) and all future patients of the CAH.

Findings include:

During an interview with the director of quality improvement on 9/25/14, at 10:55 a.m. it was confirmed that neither cardiac rehabilitation or the sleep study services had an existing quality assurance program in place.


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On 9/25/14, at 9:30 a.m. the director of quality improvement confirmed cardiac rehabilitation and sleep studies did not have any quality assurance or process improvement projects currently developed and implemented.


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On 9/24/14, at 1:00 p.m. the director of nutrition services was interviewed and verified the facility did not have a QA program process in place for nutrition services.


The CAH's undated, Quality Assurance Plan, indicated "all employees of Lakewood Health System are expected to participate in ongoing and systematic quality improvement efforts. Our quality improvement efforts will focus on direct patient care delivery processes......"