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425 NORTH ELM STREET

SAUK CENTRE, MN 56378

No Description Available

Tag No.: C0151

Based on interview and document review, the critical access hospital (CAH) failed to respond in writing to 2 of 3 persons who had filed a grievance regarding their care while being a patient in the CAH.


Findings include:


Patient (P1) had been an inpatient in April 2013. P1 wrote a letter, dated 5/1/13, stating she was unhappy about the physician's attitude and lack of sensitivity while being treated as a patient at the CAH. The letter was forwarded to the clinic director. The response available in the record was "no follow-up required". The record lacked documentation that a written response had been sent to this patient addressing her concerns.


P2 had been an inpatient in the CAH in June 2013. This patient complained on 6/10/13 that she had received generic medication versus brand name medication during her hospitalization. Documentation revealed that P2 stated "I always get the regular ones and not the generic". This grievance had been reviewed by staff and it was determined the patient had a misunderstanding about the CAH's policy on the use of generic medications. The record lacked evidence that P2 received any written response addressing the concern.


In an interview with the Quality Assurance Coordinator on 8/29/13 at 10:20 a.m., she confirmed that neither of these patients had received a written response to their grievances. She stated they should have provided the patients with a written response, as it is the CAH's policy to respond to all grievances in writing.


Review of the CAH's policy Hospital Patient/Customer Complaint/Grievance Management, policy # 41.3 last dated 12/12, indicated, "The findings of the grievance review will be communicated in writing to the grievant within 30 business days. The written response will include the name of the grievance facilitators, the steps taken to address the grievance issues, the disposition and the date of completion."

No Description Available

Tag No.: C0271

Based on observation, staff interview and document review, the critical access hospital (CAH) failed to ensure documentation of dry times for alcohol based skin preparations in anesthetizing locations for 2 of 2 surgical patients (S1 and S2) in the sample who required this type of surgical skin preparation.


Findings include:


The CAH did not implement policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the operating room suite. Centers for Medicare and Medicaid Services (CMS) had issued a Survey and Certification Memo, dated 1/12/2007, which addressed risk reduction techniques to permit safe use of alcohol based skin preparations in inpatient anesthetizing locations in CAHs. The use of alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferably as part of a systemic approach by the CAH to prevent surgery related fires.


During observation of S1's surgical procedure on 8/27/2013 at 9:27 a.m., RN-C applied an alcohol based skin preparation "chloraprep". A review of the surgical record revealed there was no documentation of the dry time of the alcohol based skin preparation


During observation of S2's surgical procedure on 8/27/2013 at 10:30 a.m., RN-D applied an alcohol based skin preparation "chloraprep". A review of the surgical record revealed there was no documentation of the dry time of the alcohol based skin preparation.


A review of the CAH's Admission to OR policy, last revised 12/2008, indicated the length of time the alcohol based skin preparation was allowed to dry was to be documented.


RN-C was interviewed on 8/27/2013 at 9:45 a.m. and verified she routinely checked to assure the alcohol based prep had completely dried prior to draping. However RN-C and the operating room supervisor confirmed that, although they routinely assure the chloraprep is dry prior to draping, documentation in the medical record was lacking to confirm such practice.


The Director of Nursing was interviewed via telephone on 8/30/2013 at 8:20 a.m. She stated the current electronic medical record, which had been implemented approximately six months earlier, did not have an area in which to document the dry time of the surgical skin preparation.

No Description Available

Tag No.: C0276

Based upon observation, interview and document review, the critical access hospital (CAH) did not ensure medication was disposed of in a secure manner in 2 of 2 operating rooms, in 1 of 1 oncology nursing office, in 1 of 1 nursing medication rooms and in 2 of 4 treatment rooms in the emergency department.


Findings include:


Medications were observed to be accessible in unsecured areas of the hospital, where patients, visitors and other persons without legal access to drugs and biologicals, were present.


OPERATING ROOM SUITE

During a tour of the operating room suite on 8/27/2013 at 10:30 a.m., containers which were labeled RCRA hazardous waste were observed in operating rooms one and two. The containers measured approximately 18 inches in height, 12 inches wide and 12 inches deep. The opening in the top of the containers measured approximately 6 inches in diameter and many bottles, vials and syringes which contained medications were visible. The medications observed in the container included syringes of Propofol (an anesthetic agent) and Succinylcholine chloride (an anesthetic muscle relaxant).


The operating room supervisor was interviewed on 8/27/013 at 10:45 a.m. and stated all unused medications in vials, syringes or other containers were disposed of in this hazardous waste container. She stated housekeeping staff had access to the operating room suite when licensed staff were not present.


Certified registered nurse anesthetist-A was interviewed on 8/27/2013 at approximately 2:00 p.m. He stated all unused medications used to administer anesthesia, except scheduled controlled medications, were disposed of in this container at the conclusion of each surgical procedure.


ONCOLOGY UNIT

During a tour of the oncology unit on 8/29/2013 at 8:15 a.m., a black RCRZ hazardous waste container which contained numerous medication vials was observed in the oncology nursing office, which was unlocked and unattended. The assistant director of nursing, who administered chemotherapy, was interviewed on 8/29/2013 at 8:25 a.m. She stated the pharmacist mixed the chemotherapy medication in the pharmacy. The pharmacist brought the vials of chemotherapy medications to the oncology department to verify the type of medication which had been mixed with the registered nurse. The unused portion of the medication was left in the vial and discarded in the hazardous waste container. She stated medications which were in the hazardous waste container were almost all chemotherapy medications. She stated housekeeping personnel had access to the nursing office when licensed personnel were not in attendance.


NURSING MEDICATION ROOM

During a tour of the nursing unit on 8/27/2013 at 2:00 p.m., a black RCRZ hazardous waste container, which contained numerous vials of medications, was observed in the locked medication room. Some of the medications observed in the container included Toradol (anti-inflammatory medication), Solumedrol (steroid medication), and Lasix (a diuretic). RN-A was interviewed at 2:15 p.m. and stated any unused medications in vials or other containers (except controlled medications) were disposed of in this hazardous waste container. She stated housekeeping personnel had access to the nursing office when licensed personnel were not in attendance.


EMERGENCY DEPARTMENT

During a tour of the emergency department on 8/26/2013 at 12:45 p.m. bronchodilator medications which included Albuterol, Atrovent, Pulmicort and Duoneb were observed in unlocked cupboards in treatment rooms one and three. RN-B was interviewed on 8/26/2013 at 2:00 p.m. and verified patients were frequently left unattended in the treatment rooms and had access to these unsecured medications.


A review of the Pharmacy Hazardous Waste Policy, dated 10/18/2006, indicated hazardous waste which included antineoplastic, vaccines, insulin and other pharmaceuticals on the Hazardous drug list must be placed into the black pharmaceutical waste boxes. Partial vials of pharmaceuticals, IV solutions with drug additives, loose tablets, capsules and inhalers are to be placed into the black pharmaceutical waste box. In addition, overtly contaminated chemotherapy garments or used chemotherapy spill clean up material is considered hazardous and placed in the black pharmaceutical waste box The policy indicated maintenance and housekeeping staff transported the used containers and stored them for disposal.


The chief pharmacist was interviewed on 8/27/2013 at 2:50 p.m. He stated the hazardous waste containers full of unused medications were transported by housekeeping staff to a locked area in the lower level of the hospital. He stated this locked area could also be accessed by maintenance staff. He stated the company who disposed of the hazardous waste containers picked them up about once every six months. The pharmacist stated the hospital did not have a policy which addressed access to drugs and biologicals in unsecured areas of the hospital where patients, visitors and other persons without legal access were present. The pharmacist stated it was not appropriate for housekeeping or maintenance staff to have access to the unused medications placed in the hazardous waste containers. The pharmacist also stated his job responsibilities included limiting access to medications to only persons with legal access to the medications.