HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff notified the patient's medical provider for 2 of 12 medication errors reviewed (Patient #11 and Patient #17) and ensure the nursing staff documented the date and time they notified the patient's medical provider for 9 of 12 medication errors reviewed (Patient #8, Patient #9, Patient #10, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #18). Failure to notify the patient's medical provider of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 6 patients on entrance to the facility and an average daily census of 4 patients per day.


Findings include:

1. Review of the policy "Documentation of Medication Error," effective 10/2019, revealed the policy lacked information instructing staff to notify the patient's physician of medication errors.

2. Review of medication errors from November 2018 to November 2019 revealed:

a. The nursing staff administered Patient #8 the wrong dose of medication on 09/09/19 at 02:43 PM. Patient #8's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #8's medical care of the medication error.

b. The nursing staff administered Patient #9 the wrong medication on 07/04/19 at 07:55 PM. Patient #9's medication error paperwork lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #9's medical care of the medication error.

c. The nursing staff administered Patient #10 a medication documented as an allergy for Patient #10 on 05/04/19 at 11:30 PM. Patient #10's medication error paperwork lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #10's medical care of the medication error.

d. The nursing staff administered Patient #11's intravenous fluids late on 05/13/19 at 12:02 PM. Patient #11's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #11's medical care of the medication error.

e. The nursing staff failed to administer Patient #12's antibiotic on 05/27/19 at 06:56 PM. Patient #12's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #12's medical care of the medication error.

f. The nursing staff administered Patient #13 a medication listed as an allergy for Patient #13. Patient #13's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #13's medical care of the medication error.

g. The nursing staff administered Patient #14 the wrong medication on 12/25/19 at 12:28 PM. Patient #14's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #14's medical care of the medication error.

h. The nursing staff administered Patient #15 the wrong medication on 02/28/19 at 04:55 PM. Patient #15's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #15's medical care of the medication error.

i. The nursing staff administered Patient #16 the wrong medication on 02/04/19 at 03:27 PM. Patient #16's medication error paperwork lacked documentation of the time nursing staff notified the practitioner responsible for Patient #16's medical care of the medication error.

j. The nursing staff administered Patient #17 the wrong dose of medication on 04/17/19 at 08:20 PM. Patient #17's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #17's medical care of the medication error.

k. The nursing staff administered Patient #18 the wrong medication on 03/13/19 at 00:00 AM. Patient #18's medication error paperwork lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #18's medical care of the medication error.


3. During an interview on 11/26/19 at 01:40 PM, the Inpatient Services Director acknowledged the medication error paperwork for Patient #11 and Patient #17 lacked documentation the nursing staff notified the patient's medical provider of the medication error. The Inpatient Services Director acknowledged the medication error paperwork lacked documentation of the date/time the nursing staff notified the patient's medical provider for Patient #8, Patient #9, Patient #10, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the endoscopy staff changed the sterile water flush bottles for 1 of 1 patients (Patient #1) in 1 of 2 Endoscopy Rooms (Endoscopy Room 1) in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The CAH identified that the endoscopy staff performed an average of 240 endoscopy procedures per year.

Findings include:

1. Observations on 11/26/19 at 9:00 AM during an endoscopy (a surgical procedure where a physician inserters a flexible camera into a patient's body) for Patient #1 in Endoscopy Room 1 revealed a bottle of Hospira 1000 mL bottle of sterile water for irrigation connected to the endoscopy equipment.

2. Review of the manufacturer's instructions on the bottle of Hospira 100 mL sterile water revealed in part, "Single dose container. Contains no bacteriostat [to prevent bacteria from growing in the sterile water]. Discard unused portion."

3. Review of policy, "Endoscopy Room Setup," last revised 03/2013, revealed in part, "Open sterile water bottle before first scope of the day...Water bottle -- changed at least daily."

4. During an interview on 11/26/19 at approximately 10:00 AM, Staff A confirmed the endoscopy staff opened a bottle of sterile water for irrigation each morning and connected it to the equipment. The endoscopy staff would only discard the bottle of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

5. During an interview on 11/26/19 at 11:00 AM, the OR Director reviewed the manufacturer's directions for the Hospira 500 mL bottles of sterile water for irrigation and acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.




II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the endoscopy staff checked the Rapicide Test Strip at the appropriate time in accordance with the manufacturer's directions while cleaning the endoscope after an endoscopy procedure for 1 of 1 patients (Patient #1). Failure to follow the manufacturer's instructions for use when cleaning endoscopes could potentially result in the cleaning process failing to remove all of the bacteria or other contaminants in the endoscope, which could then potentially infect a different patient since the staff members believed the scope was safe to use on another patient. The CAH identified that the endoscopy staff performed an average of 240 endoscopy procedures per year.

1. Observations on 11/26/19 at approximately 9:28 AM while Staff A was cleaning the endoscope used for Patient #1's endoscopy (a surgical procedure where a physician inserters a flexible camera into a patient's body) revealed Staff A used Rapicide Test Strips to measure the concentration of the disinfectant used in the endoscope reprocessor (machine used to sterilize endoscopes). Staff A dipped the test strip into the disinfectant, verbalized that the test strip should be read at around 75 seconds, but did not set a timer to monitor the time.

2. Review of the manufacturer's instructions on the bottle revealed the staff should read the test strip 75 seconds after they dipped the test strip into the Rapicide solution.

3. During an interview after the cleaning process, Staff A revealed they watched the clocked and waited approximately 1-2 minutes before checking the result of the test strip. Staff A confirmed that the manufacturer specified they should read the test strip exactly 75 seconds after dipping the test strip into the solution, and Staff A did not utilize a mechanism to ensure they waited at least 75 seconds before reading the test strip.





42028


III. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure the surgical staff sanitized their hands before donning gloves for aseptic tasks and after glove use during 1 of 1 observed surgical procedures (Patient #20). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the surgical staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The CAH's administrative staff identified the surgical staff performed 705 surgical procedures for the past fiscal year.

Findings include:

1. Review of the "Hand Hygiene Policy," revealed in part, "Purpose: to prevent the transmission of infection to patients, visitors, and staff by practicing effective hand hygiene principles. Hand hygiene is performed ... before handling an invasive device ... after removing sterile or non-sterile gloves ...""

2. Observations on 11/26/2019, beginning at 11:04 AM during Patient #19 Laporascopic Bilateral Salpingectomy (removal of the fallopian tubes through an abdominal incision with a scope to prevent further pregnancies), revealed the following:

--11:12 AM Certified Nurse Anesthetist (CRNA) F removed their non-sterile gloves and failed to perform hand hygiene.

--11:13 AM Registered Nurse (RN) C failed to perform hand hygiene prior to donning gloves before performing the abdominal prep on Patient #19 (scrubbing the patient's abdomen with a disinfecting solution prior to surgery).

--11:14 AM RN C removed their sterile gloves and failed to perform hand hygiene.

--11:15 AM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--11:40 AM Surgeon E removed their sterile gloves and failed to perform hand hygiene prior to using a pen to sign papers and rummaging through the drawers of the desk..

--11:44 AM RN C removed their non-sterile gloves, proceeded to touch the overhead light switches, and failed to perform hand hygiene.

--11:50 AM RN B removed their non-sterile gloves, proceeded to the desk to gather the patient's chart, the patient's personal belongings, used the computer mouse, and failed to perform hand hygiene.

4. During an interview on 11/26/2019 at 1:00 PM, the SDS (Same Day Surgery) and ED (Emergency Department) Director agreed they expected the surgical staff to perform hand hygiene according to the CAH's Hand Hygiene policy.

5. During an interview on 11/26/ 2019 at 1:30 PM, Quality/Infection Prevention/Risk Management Director discussed the hand hygiene policy. They used the CDC Guidelines for hand hygiene and glove usage. They educated the CAH staff using CDC guidelines. They expected the surgical staff to perform hand hygiene according to the CAH's Hand Hygiene policy.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 Surgeon (Surgeon D) had a surgical privilege list accessible to the Surgical Staff in the Operating Room prior to performing the surgical procedures. Failure to ensure Surgeon D had surgical privileges listed to perform specific surgeries could potentially result in CAH staff allowing Surgeon D to perform a procedure that he lacked competence and skill to safely perform. The CAH staff identified Surgeon D performed 9 surgeries from 5/2019 to 11/2019.

Findings include:

1. Review of Surgeon D's surgical privileges (a list of procedures the medical staff and governing body of the CAH approved the Surgeon to perform at the CAH) on 11/26/2019 revealed Surgeon D lacked a privilege list accessible on the computer in the Operating Room. Surgeon D's privilege information was not available at the time of this review. Specific surgical privileges must be available in the surgical suite and area/location where the scheduling of surgical procedures is done.

2. During an interview on 11/26/2019 at 9:15 AM, RN H and RN C verified Surgeon D's privilege list was not accessible on the computer.

3. During an interview on 11/26/2019 at 1:00 PM, the SDS (Same Day Surgery) and ED (Emergency Department) Director reviewed the privilege list available to the surgery staff and determined Surgeon D lacked a privilege list accessible to the Surgical staff.

Based on document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to perform a comprehensive activities assessment for 1 of 3 (Patients #7) closed swing bed patients. The CAH staff failed to ensure activity personnel developed and implemented an ongoing activity program that included an activities care plan. Failure to provide a comprehensive activity assessment and an activity program that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well being and independence possible. The CAH administrative staff identified a census of 3 swing patients at the time of the survey and an 85 swing bed patients and 12 self pay swing bed patients in Fiscal year 2019.

Findings include:

1. Review of policy, "Activities Program," effective 10/2019, revealed in part, "... will assess and plan personalized activities for each patient admitted to Swing Bed ... Activity plans are developed soon after admission ... but within 7 days".

2. Review of 1 of 3 closed swing bed patient medical records revealed a physician ordered swing bed services for Patient #7 on 4/26/19 and the CAH staff discharged Patient #8 on 5/20/19. The Activity Coordinator failed to complete a comprehensive activity assessment for Patient #7.

Patient #7's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

3. During an interview on 11/26/2019 at 10:00 AM, Inpatient Services Director reported Patient #7 did not met swing bed admission criteria for inpatient swing bed services, however the patient and family wanted the patient to stay and receive care from the CAH staff. Patient #7's family was willing to pay for the care out of their pocket. Inpatient Services Director acknowledged that when a patient was on self pay, they did not consider the patient a typical swingbed patient. The Inpatient Services Director verified that Patient # 7 lacked a comprehensive activities assessment and the CAH staff failed developed and implemented a comprehensive activity care plan.

Based on document review and staff interviews the Critical Access Hospital (CAH) failed to develop and implement a comprehensive person-centered careplan for 1 of 6 swing bed patient records (Patient #7) reviewed that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Failure to develop and implement a comprehensive person-centered careplan may inhibit the resident from attaining or maintaining the resident's highest practicable physical, mental and psychosocial well-being. The CAH's administrative staff identified a census of 3 swingbed patients at the onset of the survey and 85 swingbed patients and 12 swingbed self pay patients were provided swingbed services in fiscal year 2019.


Findings include:

1. Review of the policy "Comprehensive Assessment and Discharge Summary Swing Bed," last revised 11/2019, revealed in part, "PACH will develop a comprehensive care plan for each patient that is admitted to Swing Bed that includes measurable objectives and time tables to meet a patient's medical, nursing, mental, and psychosocial needs."

Review of the swing bed policy "Interdisciplinary Care Conference," last approved 10/2019, revealed in part, "Frequency and time ... Interdisciplinary Care Conferences ... minimum of once per week. ... Care Conference Objectives: identify the patient's health needs and plan of care ... promote continuity and coordination of care ... Documentation of Interdisciplinary Care Conference will address the present plan of care ..."

2 Review of Patient #7's medical record revealed the CAH staff admitted Patient #7 to swing bed services on 4/26/19 and discharged Patient #7 on 5/20/19. Patient #7's medical record lacked documentation of a comprehensive person-centered care plan and implementation of the Interdisciplinary Care Conferences to address Patient #7's ongoing care needs.

3. During an interview on 11/25/2019 at 1:00 PM, the Inpatient Services Director reported Patient #7 did not met swing bed admission criteria for inpatient swing bed services. However the patient and their family wanted the patient to stay at the CAH and receive care from the CAH staff. Patient #7's family was willing to pay for the care out of their pocket. The Inpatient Services Director acknowledged that when a patient was on self pay status, the CAH staff did not consider the patient a typical swingbed patient. The Inpatient Services Director verified that the CAH staff failed to develop and implement a comprehensive care plan, and the CAH staff failed to hold weekly Interdisciplinary Care Conferences regarding Patient #7's care.