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Based on the certification survey completed on July 11, 2013, the facility was found not in compliance with Life Safety Code requirements at CFR ?485.623(d).

Refer to Life Safety Code deficiencies at regulations; K-0050, K-0052, K-0062, K-0078, for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation and interview, the Critical Access Hospital (AH) failed to ensure that 3 of 3 ultra sound machines located in the outpatient rehabilitation center had been placed on a preventive maintenance program. This practice had the potential to effect all the patients who required the use of this equipment in physical therapy.

Findings include:

During a tour of the outpatient Sanford Seek Rehabilitation Center with the physical therapist (PT) at 11;00 a.m. on 7/9/13, 3 of 3 ultra sound machines were observed to be available for use. However, the machines lacked evidence of equipment function checks. The ultrasound machines were as noted: Intelect Legend Combo #2-C; Intelect Legend US; and the Vectra Genisys. The PT was uncertain whether there had ever been any preventive maintenance checks conducted for these machines.

The maintenance manager stated during an interview on 7/10/13 at 10:30 a.m., that the company that conducts testing of the CAH's biomedical equipment had been unaware that the Rehabilitation Center was under the jurisdiction of the hospital, therefore had never checked this equipment.

Based on interview and document review the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency.
This had the potential of affecting all patients who receive care from the CAH.

Findings include:

A review was conducted of the CAH'S policy titled, Disruption of Services-Water revised 5/13. The policy detailed a plan which stipulated the amount of water which would be needed in the event of disruption of water service. Although, this plan identified 3 proprietors who could possibly furnish water in the event of an emergency, there wasn't an agreement or contract which established a definite commitment with any of these proprietors.

The CAH's chief executive officer (CEO) provided a letter dated 7/8/13, which stated "Maynard's Foods agrees to provide bottled water to the CAH in the event that the water service to the facility is interrupted." This agreement did not describe the amount of potable or non-potable water which Maynard's Foods would provide.

In an interview with the CEO on 7/9/13 at 10:35 a.m., she agreed the agreement from Maynard's Foods lacked any specifics regarding the amounts of water or duration this proprietor would be able to provide the emergency water.

Based on interview and documentation review, the Critical Access Hospital (CAH) failed to report 3 of 6 patient's (P1, P2, P3) medication errors to the prescribing provider.

Findings include:

According to record review, P1 with a diagnosis of pneumonia, had a physician's order for Piperacillin-tazobactam (otherwise referred to as ZOSYN, an antibiotic) 3.375 grams in sodium chloride 0.9% 100 milliliters (ml). The order was to begin 4/5/13 at 1800 (6:00 p.m.) with an end date 4/11/13 at 1347 (1:47 p.m.). The medication was to be administered every 6 hours through intravenous (IV) route. Review of the patient's Medication Administration Record (MAR) indicated an error had been identified when the midnight dose on 4/6/13 was to be administered. It was determined that due to a malfunction with the IV pump, the patient had missed one dose of the medication which was to have been administered at 1830 on 4/6/13.

According to record review, P2 who had a diagnosis of pneumococcal sepsis, had a 5/23/13 physician's order for Ceftriaxone (an antibiotic) 2,000 milligrams (mg) in sodium chloride 0.9% 50 ml to be administered every 12 hours. The record further indicated a subsequent order which had been faxed to the CAH on 5/31/13, indicating the Ceftriaxone should be discontinued after 15 doses. At the time the faxed order was received, P2 had already received 17 doses.

Record review indicated P3 had a diagnosis of sudden onset of dsypnea (shortness of breathe), and had a medication order for a combination folic acid-vitamin B12-vitamin B6 tablet to be administered once daily starting 4/11/13, with an end date 4/13/13. According to the MAR this medication had not been administered on either 4/12 or 4/13/13.

In an interview with the Director of Nursing (DON) on 7/10/13 at 11:30 a.m., she stated there was no documentation to indicate these medication errors had been reported to the patients' physicians. The DON was uncertain as to why the errors had not been communicated to the physicians and stated the physician should have been informed to determine if any harm would result in these medication administration errors.

According to the CAH's policy on Medication Incidents last revised 5/23/13, "All suspected or actual medication errors shall be reported in the Midas electronic entry system upon discovery. Immediate notification of provider(s) and/or pharmacist will be made at the discretion of the charge nurse based on patient condition."

Based on document review and interview, the critical access hospital (CAH) failed to ensure a post-anesthesia evaluation had been conducted by the certified registered nurse anesthetist (CRNA) for 3 of 5 same day surgery (SDS) patient records reviewed (SDS2, SDS3 and SDS5).

Findings include:

It was noted during record review that the post-anesthesia evaluation was not evident for SDS2, who had propofol (general) anesthesia administered on 8/13/12 during a right inguinal hernia repair. SDS3 had propofol anesthesia administered during an excision of the right foot on 12/11/12 and a post-anesthesia evaluation was lacking. A post-anesthesia evaluation was also lacking for SDS5 who had a colonoscopy on 6/12/13 and had propofol anesthesia administered during the procedure.

Interview with the surgical manager on 7/9/13 at 9:20 a.m., confirmed the post-anesthesia evaluations were missing in the documentation reviewed for each of these records. The surgical manager indicated that CAH policy had dictated the evaluations were to be completed by the CRNA.

Review of the undated policy titled, Post Anesthesia Standards for CRNA, the following was noted: "All patients will receive a post anesthetic visit to assess their outcomes and address any questions before CRNA leaves the building. This will be documented on the anesthesia record."