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Based on observation, review of National Fire Protection Association (NFPA) 1 standards, and interview, it was determined the facility failed to ensure the Critical Access Hospital (CAH) was maintained in a manner to ensure the safety well-being of patients in that one of one fire barrier wall was not sealed with fire-proof sealant above the equipment room. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 1, 12.9.6.2 showed where penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, shall be protected by a system or material capable of restricting the transfer of smoke.
B. Observations on 10/23/19 at 10:30 AM of the electrical room showed one of one fire barrier wall with an approximate one inch hole surrounded by a conduit above the equipment room adjacent to the nurse's station.
C. The above finding in B was verified on 10/23/19 at 10:35 PM by the Director of Maintenance.


41857

Based on observation and interview, it was determined the facility failed to ensure an acceptable level of safety and quality was met in that medical gas tanks were being stored in combustible racks in one of one portable oxygen storage location. Failure to properly store gas tanks had the likelihood to affect all patients, visitors, and staff. Findings follow:

A. Review of NPFA 99:5.1.3.3.2 2012 edition showed storage racks for positive pressure gases shall be constructed of non-combustible or limited-combustible materials.
B. Observation on 10/22/19 at 02:15 PM of Portable Oxygen Storage showed four oxygen cylinders were stored in two combustible wooden racks. This finding was verified by the Director of Maintenance at the time of observation.

Based on document review and interview, it was determined the facility failed to ensure all essential mechanical, electrical and patient care equipment was maintained in safe operating condition in that 86 of 168 bio-medical equipment items were not maintained on an annual PM (Preventive Maintenance) program. The failed practice had the potential to impact all patients during a medical procedure. Findings follow:

A. Document review on 10/22/19 at 2:35PM showed 86 of 168 were not checked on an annual PM plan.
B. The above finding in B was verified 10/22/19 at 2:40 PM by the Director of Maintenance.

Based on observation and interview, it was determined the facility failed to provide an orderly environment for patients, staff, and visitors in that one of one portable lift machine was stored in the corridor blocking 24 inches of the path of egress. The failed practice had the likelihood to affect all patients and staff preventing full instant use of the means of egress in the event of a fire or other emergency event. Findings were:

A. Observations on 10/22/19 at 1:50 PM of the corridor between rooms 105 and 106 showed one portable lift machine stationary and plugged in to a nearby outlet, blocking 24 inches of the path of egress.
B. The above finding in was verified 10/22/19 at 1:55 PM by the Director of Maintenance.

Based on observation and interview, it was determined the facility failed to provide an orderly environment where equipment and supplies were stored in proper spaces for patients, staff, and visitors in that one of one portable lift machine was stored in the corridor blocking 24 inches of the path of egress. The failed practice had the likelihood to affect all patients and staff preventing full instant use of the means of egress in the event of a fire or other emergency event. Findings were:

A. Observations on 10/22/19 at 1:50 PM of the corridor between rooms 105 and 106 showed one portable lift machine stationary and plugged in to a nearby outlet, blocking 24 inches of the path of egress.
B. The above finding in was verified 10/22/19 at 1:55 PM by the Director of Maintenance.


41857

Based on observation and interview, it was determined the facility failed to provide an orderly environment for patients, staff, and visitors in that one of one Viking lift machine was permanently stored in the corridor, blocking 27 inches of the width of the path of egress. The failed practice had the likelihood to affect all patients and staff as it would prevent them from having full instant use of the means of egress in the event of a fire or other emergency. Findings were:

A. Observations on 10/22/19 at 01:48 PM of the corridor outside the Emergency Department showed one Viking lift machine was sitting outside a patient room doorway and plugged in to a nearby outlet, blocking 27 inches of the width of the path of egress.
B. The above finding was verified by the Director of Maintenance at the time of observation.


Based on observation and interview, it was determined the facility failed to provide an orderly environment for patients, staff, and visitors to function safely in that a stack of combustible material was stored in the small boiler room along with buckets of paint. The failed practice had the likelihood to affect all patients and staff in that there would be a dangerous fuel load posing the potential for a large fire to break out in the event of a boiler malfunction. Findings were:

A. Observations on 10/23/19 at 10:52 AM of the small boiler room showed a stack of flattened cardboard boxes and siding material was stored inside the doorway, and six paint buckets were stored on the ground near the boiler.
B. The above finding was verified by the Director of Maintenance at the time of observation.

Based on review of policy, review of Governing Body Bylaws, review of Pharmacy and Therapeutics (P&T) Committee Meeting Minutes, it was determined the Governing Body failed to ensure the bylaws and policies of the facility were implemented in that the P&T Committee failed to meet one (second 2019) of four (fourth 2018, first 2019, second 2019 and third 2019) quarters. By not meeting for a quarter, it delayed all of the recommendations to the Governing Body pertaining to; assisting in medication matters; updating policies; reviewing of medication errors and adverse drug reactions; drug utilization and antibiotic usage. The failed practice had the likelihood to affect all patients that receive treatment and care in the facility. Findings follow:

A. Review of the facility policy titled, "Pharmacy and Therapeutics Committee," dated 04/01/2005, showed the Committee was not to meet less then quarterly.
B. Review of Governing Body Bylaws showed the Committee was not to meet less then quarterly.
C. Review of Pharmacy and Therapeutics (P&T) Committee Meeting Minutes for the previous four quarters (fourth 2018, first 2019, second 2019 and third 2019) showed there was no meeting held for the second quarter 2019.
D. During an interview on 10/23/19 at 10:10 AM, the Director of Pharmacy verified the second quarter was missed.

Based on observation, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying unsafe injection practices by using the same syringes for multiple patients. By not identifying the risk this practice carries, the facility could not assure the control of the spread of infection (such as human immunodeficiency virus (HIV) and Hepatitis) and assure patient safety. This failed practice affected all nine (#26 and #37-#44) patients receiving procedures on 10/21/19 and had the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. During observation at 1:10 PM on 10/21/19 of a GI (gastrointestinal) procedure of Patient #26 in Procedure Room #1, Surveyor #1 noted after the procedure the intravenous conscious sedation nurse RN (Registered Nurse) #1 did not discard two of two syringes with medication remaining in each syringe (one labeled Fentanyl and one labeled Versed) both used during the procedure for IV conscious sedition of Patient #26. The syringes continued to remain laying on the work area of the anesthesia cart after other supplies were discarded. Surveyor #1 questioned RN #1 and asked "what do you do with these syringes lying here?" (Pointing to the two syringes labeled that were just used on the observed Patient #26 during the GI procedure). RN # 1 stated "I use them for the next case." Surveyor #1 stated, "So, after the patient that just left you keep these syringes here and use them on the next patient undergoing a procedure?" RN #1 stated, "Yes." Surveyor #1 asked "so you fill these up and use them on patients undergoing procedures until the mediation is gone?" RN #1 stated "yes I do."
B. Review of CDC guidelines titled "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)," showed "Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient".
C. During an interview on 10/21/2019 at 1:50 PM, RN #1 verified the findings in A.
D. The Administrator was informed of the findings on 10/21/19 at 2:00 PM. She sated that she was going to the procedure room and speak with RN #1 immediately. Upon return she stated to Surveyor #1 that RN #1 had admitted to her that he was using the same syringes on multiple patients who were undergoing procedures.
E. Additional information provided on 11/13/19 showed the following:
1) Review of the Register of Operation from 01/01/19 to 11/13/19 showed RN #1 was listed as the Anesthetist only on 10/21/19. Patient #26 and #37-#44 were listed on the register as receiving procedures on 10/21/19.
2) In an interview with the Chief Nursing Officer on 11/13/19 at 10:30 AM, she stated that RN #1 had only worked in the procedure room on 10/21/19 and had never worked in the procedure room prior to 10/21/19.

Based on review of Controlled Drug Administration Records, review of policy, and interview, it was determined the facility failed to document administration times for two of two (Fentanyl and Midazolam) medications administered in Surgical Services. By not documenting the administered time, the facility was not maintaining accurate records of Controlled Substances. The failed practice had the likelihood to affect all patients treated in the facility. Findings follow:

A. Review of the facility's policy titled, "Medication Administration," dated 04/01/2005, showed the time the medication was administered was to be documented.
B. Review of Controlled Drug Administration Records showed the record sheet for Fentanyl had nine separate doses administered on 10/21/19 and no time was documented for those. The Midazolam record had six separate doses administered on 10/21/19 and no time was documented for those.
C. During an interview on 10/22/19 at 1:55 PM, the Director of Pharmacy verified the administration times were not documented for the Fentanyl and Midazolam Records.

Based on observation, review of policy, and interview, it was determined the facility failed to follow acceptable standards of practice for patient safety in that they did not maintain a Malignant Hyperthermia Cart per policy, and therefore unable to treat a Malignant Hyperthermia Emergency in two of two (Emergency Department and Surgical Services) areas toured that used depolarizing muscular relaxants. By not adhering to the acceptable standards of practice as set forth by the Malignant Hyperthermia Association of the United States (MHAUS), the facility could not assure they were prepared for a Malignant Hyperthermia Emergency. The failed practice had the potential to affect all patients admitted to the Emergency Department and Surgical Services for procedures. Findings follow:

A. Review of the facility's policy titled, "Malignant Hyperthermia Protocol," revised on 05/01/09, showed the facility was to maintain a Malignant Hyperthermia Cart Inventory. The cart was to have 4 drawers with listed supplies; 36 vials of Dantrolene; and water to dilute the Dantrolene in it.
B. During a tour of the facility on 10/22/19 from 1:15 PM to 2:15 PM, observation showed the facility did not maintain a Malignant Hyperthermia Cart.
C. During an interview on 10/22/19 at 2:28 PM, the Director of Pharmacy verified there was not a Malignant Hyperthermia Cart.

Based on observation, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying unsafe injection practices by using the same syringes for multiple patients. By not identifying the risk this practice carries, the facility could not assure the control of the spread of infection (such as human immunodeficiency virus (HIV) and Hepatitis) and assure patient safety. This failed practice affected all nine (#26 and #37-#44) patients receiving procedures on 10/21/19 and had the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Review of CDC guidelines titled "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)," showed "Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient".
B. During observation at 1:10 PM on 10/21/19 of a GI (gastrointestinal) procedure of Patient #26 in Procedure Room #1, Surveyor #1 noted after the procedure the intravenous conscious sedation nurse RN (Registered Nurse) #1 did not discard two of two syringes with medication remaining in each syringe (one labeled Fentanyl and one labeled Versed) both used during the procedure for IV conscious sedition of Patient #26. The syringes continued to remain laying on the work area of the anesthesia cart after other supplies were discarded. Surveyor #1 questioned RN #1 and asked "what do you do with these syringes lying here?" (Pointing to the two syringes labeled that were just used on the observed Patient #26 during the GI procedure). RN # 1 stated "I use them for the next case." Surveyor #1 stated, "So, after the patient that just left you keep these syringes here and use them on the next patient undergoing a procedure?" RN #1 stated, "Yes." Surveyor #1 asked "so you fill these up and use them on patients undergoing procedures until the mediation is gone?" RN #1 stated "yes I do."
C. During an interview on 10/21/2019 at 1:50 PM, RN #1 verified the findings in B.
D. The Administrator was informed of the findings on 10/21/19 at 2:00 PM. She sated that she was going to the procedure room and speak with RN #1 immediately. Upon return she stated to Surveyor #1 that RN #1 had admitted to her that he was using the same syringes on multiple patients who were undergoing procedures.
E. Additional information provided on 11/13/19 showed the following:
1) Review of the Register of Operation from 01/01/19 to 11/13/19 showed RN #1 was listed as the Anesthetist only on 10/21/19. Patient #26 and #37-#44 were listed on the register as receiving procedures on 10/21/19.
2) In an interview with the Chief Nursing Officer on 11/13/19 at 10:30 AM, she stated RN #1 had only worked in the procedure room on 10/21/19 and had never worked in the procedure room prior to 10/21/19.


Based on observation, review of Centers for Disease Control and Prevention (CDC) and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in one of one gastrointestinal (GI) procedure room. By not identifying the risk this practice carries, the facility could not assure the control of the spread of infection and patient safety. This failed practice has the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Review of CDC guidelines titled, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)," showed, "If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated clean medication preparation area (e.g., nurses station), away from immediate patient treatment areas."
B. During a tour of the GI procedure area on 10/22/19 at 1:30 PM, observation showed one of one Endoscope Ink Marker 10 ml (milliter) multi-dose vial was open on the GI scrub cart in Procedure Room #1. The multi-dose vial was stored in the immediate patient care area and available for patient use.
C. Findings in B were verified on 10/22/19 at 1:35 PM by the CNO (Chief Nursing Officer).


Based on review of manufacturer's instructions, observation and interview, it was determined the facility failed to prevent and control the spread of infection in that the Rapicide Glutaraldehyde Test Strips, the Quality Control Procedure to check the effectiveness of the Rapicide Glutaraldehyde Test Solution was not performed at the opening of each new bottle in one of one unit (Central Sterile Room). Failure to perform the Quality Control Procedure when each new bottle was opened did not ensure the accuracy of the strips and did not guarantee the accuracy of the daily checks of the Rapicide Glutaraldehyde Test Solution. The failed practice had the potential to affect all patients whose care required high level disinfected equipment. Findings follow:

A. Review of the manufacturer's instructions located in the Rapicide Glutaraldehyde Test Strip package insert showed the strips should be tested on each newly opened test strip bottle.
B. Review of sterile cleaning logs on 10/22/19 at 9:00AM showed no log of Rapicide Glutaraldehyde Test Strips being tested.
C. During an interview with RN (Registered Nurse) #1 on 10/22/19 at 10:00AM, she stated there was no testing of the strips being performed, and verified findings in A and B.


38994

Based on review of Centers for Disease Control and Prevention (CDC) guidelines, observation and interview it was determined the facility failed to provide safe medication preparation in that 8 emesis basins containing 2 syringes each that were pre filled with Versed and Fentanyl were found inside the immediate patient treatment area. Failure to prepare medication immediately prior to each case did not ensure inadvertent contamination of the medication prior to use. The failed practice had the potential to affect all patients receiving intravenous conscious sedation for procedures. Findings follow;

A. Review of the CDC injection safety, medication preparation questions states "from an infection control perspective, the safest practice is to prepare an injection as close as possible to the time of administration to the patient. This is to prevent compromised sterility (microbial contamination or proliferation) or compromised physical and chemical stability of the medication."
B. Observations made on 11/13/19 at 10:15 AM of the patient treatment area showed 8 emesis basins with 2 prefilled syringes each of Versed and Fentanyl had been prepared prior to the beginning of any scheduled case for the day.
C. During interview with Registered Nurse (RN) # 3 the above findings in A and B were verified.

Based on review of policy, list of medication errors for 01/01/19 through 06/30/19, review of clinical records, and interview, it was determined the facility failed to maintain accurate records in that seven of seven (#1-#7) incidents of a medication error were not documented in the chart of the patient that received the medication in error. By not documenting the medication errors, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that are treated at the facility. Findings follow:

A. Review of the facility's policy titled, "Medication Administration," showed all medications administered to a patient shall be documented in the patient's medical record, including medications given in error.
B. Review of medication errors for 01/01/19 through 06/30/19 revealed seven incidents.
C. Review of the seven medication errors in the clinical records showed there was no evidence of documentation of the medication error.
D. During an interview on 10/23/19 at 11:08 AM, the CNO (Chief Nursing Officer) verified the medication errors were not documented in the clinical records.


40282

Based on policy and procedure review, clinical record review, and interview, it was determined the facility failed to ensure physician's orders were authenticated within 24 hours for four (#1, #6, #7, and #9) of 10 (#1-#10) inpatient records. By not authenticating orders within 24 hours, the facility could not ensure the care being provided was in accordance with the physician's plan of care. The failed practice had the likelihood to affect all patients who were admitted to the facility Findings follow:

A. Review of policy on 10/24/19 at 10:00M AM titled, "Orders/Verbal Orders" showed verbal orders shall be authenticated by the physician issuing the order but in no event longer than a 24 hours from issuance of order.
B. Clinical record review showed the following orders were not authenticated within 24 hours:
1) Patient # 1's Nursing Order #1100, Ancillary Order #1500, and Pharmacy order #8646 were not signed within 24 hours.
2) Patient # 6's Ancillary Order #1400, and Pharmacy Orders #13317, and #13316 were not signed within 24 hours.
3) Patient # 7's Pharmacy Order #14233, and Nursing Order #400 were not signed within 24 hours.
4) Patient # 9's Nursing Orders #1000, and #900 and Pharmacy Orders #15297, and #15267, and Ancillary Order #1400 were not signed within 24 hours.
C. During an interview on 10/24/19 at 1:30 PM, the CNO (Chief Nursing Officer) verified the physician's orders were not signed within 24 hours.

Based on review of policies, patient death records, and interview, it was determined the facility failed to have consistent policies and procedures to follow in the event of a patient death and failed to provide evidence that ARORA (Arkansas Regional Organ Recovery Agency) was notified for three (#22, 23 and 24) of five (#21-26) deaths that occurred in May 2019. By not providing evidence that ARORA was contacted on each death, the facility could not assure they were following their policy and fulfilling their Organ Procurement responsibilities. The failed practice had the likelihood to affect all persons who pass away at the Facility. Findings follow:

A. Review of the facility's policy titled, "Death, Patient," dated 02/21/2011, showed that ARORA must be notified of every death that occurs, even if it is a coroner's case. If the patient does not meet criteria, facility staff were to get a reference number from the ARORA representative.
B. Review of patient death records for May 2019 revealed death records for Patients # 22, 23 and 24 had no evidence ARORA was contacted.
D. During an interview on 10/23/19 at 9:26 AM, the Director of HIM (Health Information Management) verified there was no evidence that ARORA had been contacted for the above mentioned three patients.

Based on interview and clinical record review, it was determined the facility failed to perform an activities assessment or provide activities for 10 of 10 (#27-37) Swing-Bed patients. Failure to perform an activities assessment and provide activities did not allow the Swing-Bed patient and/or family to be knowledgeable of available activities and choose which activities they would like to participate in. The failed practice had the potential to affect any Swing Bed patient. Findings follow:

A. Interview with CNO (Chief Nursing Officer) on 10/23/19 at 10:30 AM she stated they had not had an Activities Director until two weeks ago.
B. Review of clinical records showed Patients #27-37 did not have a comprehensive activity assessment completed and no documentation of activities.
C. The findings in B were verified with the Swing-Bed Coordinator on 10/24/19 at 1:00 PM.

Based on policy and procedure reviews, clinical record reviews, and interview, it was determined the facility failed to follow their policy and procedure to maintain complete swing bed clinical records in that 10 of 10 (# 27-37) Swing Bed patients did not have a comprehensive assessment. Failure to ensure a comprehensive assessment was performed did not ensure the facility followed policy as well as provided the appropriate level of care as required by the policy. The failed practice affected Patients # 27-# 37. The findings follow:

A. Review of the policy and procedure titled, "Resident Assessment Addendum E," received from Swing-Bed Coordinator on 10/21/19 at 3:00 PM showed "Swing bed staff will conduct a comprehensive, accurate and standardized assessment of each patient's functional capacity."
B. Review of the clinical records of Patients #27-#37 showed no evidence of a comprehensive assessment.
C. During an interview with the Swing-Bed Coordinator on 10/24/19 at 1:00 PM findings in A and B were verified.

Based on review of Physical Therapists' (PT) Job Description and Performance Appraisal, review of Physical Therapist's personnel files, and interview, it was determined one of one (#1) physical therapist did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification. By not having evidence of these qualifications, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Review of Physical Therapists' Job Description and Performance Appraisal, showed that one of the PT's job responsibilities was to maintain CPR certification.
B. Review of personnel file for Physical Therapist #1 showed the CPR certification expired 09/2019.
C. During an interview on 10/23/19 at 2:49 PM, the CNO (Chief Nursing Officer) verified the findings in B and that the PT had seen 12 patients while having an expired CPR certification.