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Based on observation, interview and document review, the critical access hospital (CAH) failed to store toxic cleaning products in a secure location. This deficient practice had the potential to affect patients and the public.

Findings include:

Non-Acid Disinfectant Bathroom Cleaners (NABC) were stored in an unlocked cupboard in the south and west soiled utility rooms located on the nursing unit.

It was observed during a tour of the second floor nursing unit at 8:30 a.m. on 7/6/12, that four bottles of NABC were located in unlocked cupboards in the soiled utility rooms on the south and west wings. A bottle of Oxivir (a disinfectant/deoderizer/sanitizer) was also located in the unlocked cupboard in the west soiled utility room. The bottles were all labeled with "Keep out of reach of children". The surveyor was accompanied by the acute patient services director who confirmed at 8:30 a.m. on 7/6/12, that these cleaning products were supposed to be securely stored. The soiled utility rooms were located next to patient rooms and were not within view of the nursing unit.

The Material Safety Data Sheets indicated, "Precautions: Handling & Storing: Keep out of reach of children" and "rubber gloves and splash goggles are recommended with contact".

Interview with the chief clinical officer at 9:00 a.m. on 7/9/12, confirmed the unsafe practice of storing cleaning products in unlocked cabinets. She indicated the CAH had re-located the storage of these products and were considering a more permanent system to ensure the security in order to assure no public access.

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to ensure safe surgical practices were documented to ensure proper procedures were followed related to use of alcohol based skin preparations in anesthetizing locations to prevent the risk of surgical fires. This practice was evident for 4 of 4 patients (S4, S7, S10 and S11) in the sample who required this type of surgical prep.

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 surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing 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 record review it was noted that alcohol based skin preparations had been utilized during four laparoscopic cholecystectomies on the following dates: S4-4/23/12, S7- 5/2/12, S10-4/23/12 and S11- 6/25/12. Review of the surgical case records revealed that the alcohol based skin prep "chloraprep" had been used for these surgical cases.

The facility's policy for Surgical Skin Preps, identified the following procedure: " A. When preparing the skin for a surgical procedure, special considerations should include allowing sufficient time for complete evaporation of any flammable antiseptic agent (e.g., alcohol, alcohol-based preparations) to reduce the possibility of fire; and preventing antiseptic agent pooling beneath patients, pneumatic tourniquet cuffs, electrodes, or electrosurgical unit dispersive pads to reduce the risk of chemical burns."

Interviewed staff verified that they routinely checked to assure the alcohol based prep had completely dried prior to draping. However, the CAH staff confirmed they had not been documenting the dry time of the alchohol based prep. Interview with the registered nurse operating room manager at 2:30 p.m. on 7/6/12, confirmed that although they routinely assure the chloraprep is dry prior to draping, documentation in the record was lacking to confirm such practice.

Based on interview and document review, the critical access hospital (CAH) failed to assure the certified registered nurse anesthetist (CRNA) documented a post-anesthesia evaluation for each surgical patient including: cardiopulmonary status, level of consciousness and any complications occurring during post-anesthesia recovery, for 8 of 12 outpatient/inpatient surgical records reviewed (S1, S2, S3, S4, S5, S6, S7, and S8).

Findings include:

Nine of twelve surgical records reviewed, including both inpatient and outpatient, lacked documentation by the CRNA of a complete post-anesthesia evaluation. The CRNA failed to document: cardiopulmonary status, level of consciousness; follow-up care and whether there were any complications during recovery for each surgical patient.

The post-anesthesia documentation by the CRNA for each of the eight records identified included: "satisfactory recovery for anesthesia"; Records that included post-anesthesia care were the following: S1-colonoscopy & endoscopy dated 3/14/12; S2-tonsillectomy & adenoidectomy dated 4/12/12; S3- knee arthroscopy dated 4/16/12; S4-cholecystectomy dated 4/23/12; S5-laproscopic cholecystectomy dated 4/24/12; S6-endoscopy and colonoscopy dated 4/30/12; S7-laproscopic cholecystectomy dated 5/2/12; and S8-PEG (percutaneous endoscopic gastrostomy) dated 5/9/12.

Review of the CAH's policy, AN-640 Post Anesthesia Care, the following procedure was noted: Anesthesia documentation should include recording of a post-op evaluation including at least one note describing the presence or absence of any anesthesia-related complications. Each note shall specify date and time and be documented no longer than 48 hours post-op.

The Chief Clinical Officer was interviewed at 1:00 p.m. on 7/10/12. She confirmed the post operative anesthesia documentation completed for these eight patients had been completed by one CRNA, and verified the documented post anesthesia recovery evaluations lacked the required minimum components.