HospitalInspections.org

Based on observation, document review and interview, it was determined the critical access hospital (CAH) failed to ensure 2 of 2 crash carts were checked on a daily basis according to CAH policy.

1. On 7/22/14 at 9:00 a tour of the emergency department was conducted with the Manager of the Emergency Department (E #7). During the tour the "crash cart checklist" on the emergency cart in the trauma room had missing signatures from 7/3/14 thru 7/10/14.

2. On 7/21/14 at 12:10 PM a tour of medical/surgery department was conducted with the Medical/Surgery Manager (E #1). During the tour the "crash cart checklist" on the crash cart of this unit had missing signatures from 7/4/14 thru 7/20/14.

3. On 7/23/14 at 2:30 PM the CAH policy "Emergency Crash Cart and Equipment Checks" was reviewed. Under "POLICY:" it indicated "Emergency crash carts will be checked daily..."

4. On 7/22/14 at 9:45 AM an interview with E #7 was conducted. During the interview E #7 verbalized the signatures were missing on the checklist for the dates 7/3/14 thru 7/10/14 and should have been signed off by the responsible nurse.

5. On 7/21/14 at 12:30 PM an interview with E #1 was conducted. During the interview E #1 verbalized the crash cart should have been checked and initialed twice a day every day.

A. Based on document review, observation, and interview, it was determined the critical access hospital (CAH) failed to ensure all food items were dated when stored. This has the potential to affect all patients and staff utilizing the food service at the CAH.

Findings include:

1. The CAH's policy and procedure titled, " Receiving and Storage of Food Supplies" (With a revised date of 2/12/08) was reviewed on 7/22/14 at 10:45 AM. There was no documentation to indicate that dietary personnel were to date and or time food items when they were opened. This precludes personnel from knowing how long the food was stored.

2. During a tour of the Dietary department, conducted on 7/22/14 at 10:20 AM, the following were observed: in the walk-in cooler - 5 chocolate chip cookies wrapped in clear plastic wrap with no date or time it was stored. One (1) large metal pan (with a metal lid) with the contents identified as lettuce salad with no date/time it was prepared. One (1) opened (12 pound) white bucket of potato salad with no date/time it was opened. In the dry goods storage room there were 2 medium sized clear plastic containers (with powders in them. One (1) was labeled brown gravy and the other labeled chicken gravy) without any dates/times on them to indicate when they were opened. 1 gallon of partially used Kikoman Soy Sauce without any date of when it was opened.

3. During an interview with the Dietary Department Manager (E#-8), conducted on 7/23/14 at 10:50 AM, it was stated that any food item that is opened should have the date written on the container.

B. Based on document review, observation, and interview, it was determined the CAH failed to ensure all stock food items were rotated in accordance with first in/first out (FIFO). This has the potential to affect all patients and staff utilizing the food service at the CAH.

Findings include:

1. The CAH policy and procedure titled, "Receiving and Storage of Food Supplies" (With a revised date of 2/12/08) was reviewed on 7/22/14 at 10:45 AM. It indicated under, "PURPOSE: II. Storage: a. i. Place new items behind old items. Bring old items to be used first to front of shelf."

2. During a tour of the dietary department, conducted on 7/22/14 at 10:20 AM, the following were observed: in the dry goods storage room - Nine (9) large plastic containers of various salad dressings (Italian, Thousand Island, Ranch, etc.) with no dates received. Four (4) large plastic containers of dill pickles with no dates of receipt. Two (2) #10 cans of asparagus without any date of receipt. Without the containers being marked with the date of receipt, dietary personnel cannot insure the food items are being properly rotated.

3. During an interview with the Dietary Department Manager (E#-8), conducted on 7/23/14 at 10:50 AM, it was stated that she would be unable to verify if the dietary personnel were actually using FIFO without the containers being labeled with a date of receipt.

Based on document/record review and staff interview it was determined in 2 of 20 (Pt. #1, Pt# 5) clinical records reviewed, the facility failed to ensure vital signs were performed in accordance with Physician orders and Critcal Access Hospital policy.


Findings include:

1. The policy and procedure titled, "Registered Nurse-Job Title" (revised/reviewed 01/13) was reviewed on 7/22/14 at approximately 1:00 PM It noted "Essential Duties And Responsibilities-Takes temperature, pulse, blood pressure, and other vital signs... Documents clear and concise data for all patient care...Documents per policies in medical record. Evaluates and interprets physician orders. Enters and processes physician's orders."

2. The policy and procedure titled, "Department: Nursing Service- Subject: Clinical Record Service-Charting" (revised 10/01/12) was reviewed on 7/22/14 at approximately 1:15 PM The policy required, "Policy: A. A complete record of patient care and progress documents all aspects of the patient's care... B. The patient medical record is a legal record...An accurate and complete chart..."

3. The clinical record of Pt. # 1 was reviewed on 7/22/14 at approximately 1:30 PM. Pt. #1 was admitted with a diagnosis of pnuemonia on 11/11/13. Physician orders dated 11/11/13 at 1:35 AM, notes "VS (vitals signs) Q (every) 2 hours x 4, then Q 4 hrs x 4, then Q shift" (vital signs every two hours taken four times, then every four hours, taken four times, then every shift). Pt # 1's clinical record lacked documentation of the full series of vital signs as ordered with the exception of 11/11/13 at 1:30AM, 3:18AM, 5:00AM, 7:08 AM, 4:02 PM, and every shift thereafter.

4. The clinical record of Pt. #5 was reviewed on 7/22/14 at approximately 3:30 PM. Pt. #5 was admitted with a diagnosis of dizziness on 7/21/14. Physician orders dated 7/21/14 at 6:44 PM, notes "VS Q 2 hours x 4, then Q 4 hrs x 4, then Q shift" ( vital signs every two hours taken four times, then every four hours, taken four times, then every shift). Pt # 5's clinical record lacked documentation of the full series of vital signs as ordered with the exception of 7/21/14 at 7:34 PM, 10:59 PM, 11:06 PM, 7/22/14 at 12:06 AM, 1:25 AM, 3:30 AM, 5:12 AM, 7:56 AM, and 2:43 PM.

5. During an interview conducted on 7/22/14 at 4:00 PM, Registered Nurse-Infomation Specialist (E #7) stated the blanks on all patient clinical documents should be filled out completely and doctors' orders should be followed.

Based on record review and staff interview it was determined in 1 of 20 (Pt. #3) clinical records reviewed, the facility failed to ensure records were complete and accurate.

Findings include:

1. The policy and procedure titled, "Registered Nurse-Job Title" (revised/reviewed 01/13) was reviewed on 7/22/14 at approximately 1:00 PM It noted "Essential Duties And Responsibilities-. Documents clear and concise data for all patient care...Documents per policies in medical record."

2. The policy and procedure titled, "Department: Nursing Service-Subject: Admission Assessment" (revised 8/31/12) was reviewed on 7/22/14 at approximately 1:30 PM The policy required, "Policy: Nursing, Every Patient will have a patient assessment completed within 12 hours of admission. ... Procedure: 1. Complete the EMR (electronic medical record) Inpatient Admission Assessment form (electronic form)"

3. The policy and procedure titled, "Department: Nursing Service- Subject: Clinical Record Service-Charting" (revised 10/01/12) was reviewed on 7/22/14 at approximately 1:15 PM The policy required, "Policy: A. A complete record of patient care and progress documents all aspects of the patient's care... B. The patient medical record is a legal record...An accurate and complete chart..."

4. The clinical record of Pt. # 3 was reviewed on 7/22/14 at approximately 2:00 PM. Pt. #3 was admitted with a diagnosis of septicemia (infection of the body) on 6/8/13. Pt #3's "Initial Patient Assessment" lacked documentation in sections: "EENT" (ears, eyes, nose, and throat); "Oral Motor": "Psychological"; "Respiratory"; "Cardiovascular"; "GI" (gastrointestinal); "Integumentary"; and "Pain".

5. During an interview conducted on 7/22/14 at 4:00 PM, Registered Nurse-Information Specialist (E #7) stated the blanks on all patient clinical documents should be filled out completely. E #7 stated the "EMR Inpatient Admission Assessment form" is the same document as the "Initial Patient Assessment" and all sections of the form should be filled out.

Based on document review and interview, it was determined the critical access hospital (CAH) failed to ensure it's quality program sent out medical records on each of the physician's providing patient care at the CAH for peer review. This has the potential to affect all patients receiving care at the CAH.

Findings include:

1. The CAH's policy and procedure titled, "Peer Review Policy" (With an effective date of 3/21/13) was reviewed on 7/23/14 at 10:45 AM. It indicated under, "I. Purpose: Peer review is properly conducted when based on evidence of objective trend measurement and/or quality concerns for clinical management, and evaluation of outcomes. A quality concern is a concern with a significant or potential for a significant, adverse effect on the patient's wellbeing. "The peer review in this facility will be conducted both where focus is on an individual practitioner...as well as the on-going surveillance of the professional performance of all physicians who have delineated clinical privileges. Peer review will also be conducted in order to evaluate the competence of each licensed independent practitioner's performance, in accordance with the renewing of credentials."

2. A list of the physicians providing patient care at the CAH was provided on 7/24/14 at 10:35 AM by the Risk Manager (E #5). The list indicated no records had been sent for outside peer review on any of the physicians providing patient care at the CAH.

3. During an interview with (E#-5), conducted on 7/24/14 at 10:45 AM, E#-5 stated no records have been sent out for peer review but that the physician's records could be easily be sent to an outside agency for peer review.