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Based on observation, record review and interviews, the governing body failed to ensure a contracted service, hemo dialysis, was provided in a safe and effective manner.

Findings Included:

1. During a tour of the dialysis room on 4/08/14 at 11:45 AM with Personnel #16, the reverse osmosis (RO) water system and the dialysis machine were noted to have no electrical safety test, no preventative maintenance, no routine maintenance, no monthly biological results and/or no semiannual Association for the Advancement of Medical Instruments (AAMI) results for the year. The dialysis machine had a "PM sticker dated 4-07 due 4-08."

2. During an interview on 4/08/14 at 11:45 AM, Personnel #16 confirmed they did not have the water system logs for 2014 completed at the facility. Personnel #16 confirmed the RO water system did not have the required testing. Personnel #16 stated the RO water system had been delivered 4/04/14 to the hospital and had been used 4/04/14 and 4/07/14 to treat Patient #1. Personnel #16 stated she would have the results brought to the hospital.

3. During an interview on 04/08/14 at 1:50 PM, Personnel #15 was asked when action was taken for unacceptable microbiological results on the water system. Personnel #15 stated, "we take the culture (to send out for testing), then disinfect (the water system) with minnacare within 72 hours." Personnel #15 presented the results of microbiological testing and a log which showed the completed minnacare disinfection for 01/01/14 through 03/04/14. The surveyor compared the logs which revealed 01/09/14 microbiological results were unacceptable and there was no prompt disinfection of the water system. Personnel #15 was present for the comparison and confirmed the findings.

4. During an interview on 04/09/14 at 11:50 AM, Personnel #13 was informed the dialysis contractor had brought machines into the facility on 04/04/14. Personnel #13 stated that he was not notified by the contractor.

In an interview with the surveyor the morning of 4/09/14 the Chief Executive Officer confirmed the facility had not provided oversight for the dialysis provider.
The 2/01/07 "Incoming Equipment Inspection and Preparation" policy required, "Ensure that all new equipment arriving at the hospital facility is fully functional and meets all safety and compliance standards...The machine will be cultured...results verified to be within acceptable limits before the machine is made available for patient use."
The 2/01/07 "Water System Monitoring Requirements" policy required, "To continually ensure that the quality of the water used for the acute dialysis applications meets (Association for the Advancement of Medical Instruments) AAMI requirements, chemical analysis of the water shall be performed on a semi-annual basis and microbiological analysis shall be performed on a monthly basis..."

Based on observation, record review and interviews, the facility failed to ensure patient's received care in a safe setting, in that:

A. The documentation of 3 of 3 crash carts (Cart #1, #2 and the ER cart) did not include the required daily inspections to ensure safe functioning for patient use from 03/08/14 through 04/05/14;

B. The documentation of 1 of 1 second floor patient Glucometer did not include the required daily controls to ensure safe functioning for patient use from 03/04/14 through 03/29/14; and

C. The documentation of 1 of 1 second floor patient medication refrigerator did not include the required daily temperatures to ensure proper temperature for safe patient medication storage from 03/16/14 through 03/31/14.

Findings Included:

During a tour and interview on 4/07/14 at 1:35 PM with Personnel #5, the crash cart logs of Cart #1, #2, and the ER cart were reviewed. The refrigerator and glucometer logs were reviewed.

A. There was no documentation that Cart #1 was checked 3/29/14, 3/25/14, and 3/18/14.

There was no documentation that Cart #2 was checked 3/29/14, 3/25/14, 3/18/14, and 3/8/14.

There was no documentation that the ER Cart was checked 4/05/14, 3/29/14, 3/25/14, 3/23/14, 3/22/14, 3/18/14, 3/9/14, and 3/08/14.

The 2/18/13 "Emergency Crash Carts" policy, required, "The crash carts will be maintained at a constant state of readiness and monitored daily by nursing..."

B. There was no documentation that the Glucometer had controls completed for 3/29/14, 3/27/14, 3/20/14, 3/13/14, 3/8/14, and 3/4/14.

C. There was no documentation that the "Second Floor Locked Medroom" refrigerator had temperatures checked for 3/31/14, 3/27/14, 3/22/14, 3/21/14, 3/20/14, 3/19/14, and 3/16/14.

The 1/24/13 "Refrigeration Monitoring and Cleaning" policy, required, "Unit staff is responsible for monitoring of temperatures, documenting temperatures..."

Personnel #5 witnessed the above findings of A, B, and C. Personnel #5 said they should have been checked by nursing.

Based on record review and interview, the facility failed to maintain an ongoing program to measure indicators to identify and reduce medical errors for 1 of 4 quarters in 2013, in that, there were no measures evaluated for the fourth quarter of 2013 for the Infection Control, Pharmacy, Medical Records, Utilization Review Committees, and contracted dialysis services for the fourth quarter of 2013.

Findings Included:

1) During a review of the Governing Board Meeting Minutes dated January 30, 2014 the surveyor located the Quality Management and Performance Improvement Committee Meeting Minutes. The Quality Meeting information was dated January 27, 2014. The Pharmacy and Therapeutics Committee, the Medical Record Policy and Forms Committee, Medical Record Review Committee, and Utilization Review did not report any data identified during the fourth quarter of 2013.

The Quality Indicator Report was reviewed. A statement included, "General discussion occurred because of multiple areas of no information being reported."

There was no infection control data submitted to the committee and no evaluation of the contracted dialysis provider in the fourth quarter of 2013.


2) In an interview with the surveyor at 1130 AM on 4/08/14, the Chief Executive Officer stated there was no formal Quality Data available for the first quarter of 2014 that included evidence of ongoing quality performance and contracted dialysis services since October of 2013.

Based on record review and interview, the facility failed to ensure the nursing staff kept current a nursing care plan for each patient, in that, 2 of 5 care plans (Patient #5 and #8) were not reviewed/updated as required and did not included interventions to reach the goals specified.

Findings Included:

The 3/21/14 "Nursing IDT Care Plan" for Patient #8 reflected, "Patient Problems...Knowledge Deficit (no reason)...Interventions (blank)...Alteration in comfort: Pain...Interventions (blank)...Alteration in Skin Integrity: decreased mobility, stage 4 sacral...Interventions (blank)...Daily Review of Nursing Problem List..."
There was no documented nursing shift review of Patient #8's care plan for the 3/29/14 AM shift, 3/28/14 AM shift, 3/27/14 AM shift, 3/27/14 PM shift, 3/25/14 AM shift, 3/24/14 AM shift, and 3/24/14 PM shift.

The 4/02/14 "Nursing IDT Care Plan" for Patient #5 reflected, "Patient Problems...Knowledge Deficit(no reason)...Interventions (blank)...Alteration in comfort: Pain...Interventions (blank)...Self Care Deficit: Pneumonia, Resp Failure...Interventions (blank)...Impaired Gas Exchange: Pneumonia, Resp Failure...Expected Outcomes (blank)...Interventions (blank)...Daily Review of Nursing Problem List..."

There was no documented nursing shift review of Patient #5's care plan for the 4/03/14 AM shift.

During an interview on 4/08/14 at 11:29 AM, Personnel #4 was informed of the above findings. Personnel #4 confirmed the findings. Personnel #4 was asked when was the nurse expected to review the care plan. Personnel #4 stated "each patient care shift."

The 2/18/13 "Provision of Care Nursing Process" policy, required, "The plan of care contains goals based on the nursing assessment and should reflect...interventions shall be included...includes nursing measures that will facilitate the medical care prescribed and that will endeavor to restore, maintain, or promote the patient's well-being..."

The 2/22/13 "Nursing - Case Management Plan of Care" policy required, "to provide an individualized, interdisciplinary plan of care...appropriate to the...limitations and goals...implemented...progress is then evaluated based on...response to treatment...progress towards goals and expected outcomes...Each discipline will...assure the completion of therapeutic interventions as indicated in the plan of care..."

Based on record review and interview, the facility's medical records were not complete and accurately written, in that:

A. 2 of 2 dialysis patients (Patient #1 and #28) who received dialysis treatments had incomplete "Physician Hemodialysis Orders;"

B. 2 of 2 dialysis patients (Patient #1 and #28) had no documented clarification as to the differences between the physician's orders and the treatments initiated;

C. 2 of 2 dialysis patients (Patient #1 and #28) who received a hemodialysis treatment had no documentation as to why the orders for the treatment of hypotension were not followed and/or clarified;

D. 2 of 2 dialysis patients (Patient #1 and #28) who received a hemodialysis treatment had no documentation as to why the orders for heparin, blood flow rate and dialysis flow rate were not followed and/or documented; and

E. 2 of 2 dialysis patients (Patient #1 and #28) who received a hemodialysis treatment had no documentation as to what time the ordered medications were given to the patient.

Findings Included:

A. The physician did not document the type of dialyzer for the treatment for Patient #1, the length of time for the dialysis treatment for Patient #28, number of hours for the sodium prescription for Patient #1 and #28, and the time of the dialysis order for Patient #1.

B. Patient #1 was treated on 04/04/14 and 04/07/14 with a "160" dialyzer without a physician's order for this type of dialyzer. The sodium prescription type and number of hours was not documented for the 04/04/14 and 04/07/14 treatments for Patient #1.

Patient #28 was treated on 01/20/14 and 01/22/14 for three hours without a physician's order for this amount of time. The sodium prescription type and number of hours was not documented for the 01/20/14 and 01/22/14 treatments for Patient #28.

C. Patient #1 had an order to "Keep SBP (systolic blood pressure) > 100" and had no order for the treatment of hypotension. Patient #1 experienced hypotension during the treatment on 04/04/14 from 6:30 PM through 8:15 PM. Patient #1 was treated for hypotension via ultrafiltration adjustment. There was no documentation of physician notification of the hypotension, and no request for an order for the treatment of hypotension. The patient was returned to the care of the facility staff with a systolic blood pressure (SBP) less than 100.

Patient #28 had an order to "Keep SBP > 100" and had three orders for the treatment of hypotension which did not include ultrafiltration adjustment. Patient #28 experienced hypotension during the treatment on 01/22/14 at 7:45 PM and was treated for hypotension via ultrafiltration adjustment. There was no documentation of physician notification of the hypotension, and no request for an order for the use of ultrafiltration adjustment for the treatment of hypotension.

D. Patient #1 had orders for a blood flow rate of 400 mL/min, dialysate flow rate of 600 mL/min, and heparin orders of "Load: 2000 units IVP; Hourly 500 units IV." (Heparin load is given to the patient prior to the start of the treatment and the Hourly is to be given during the treatment.)
On 04/04/14 the patient received a dialysis treatment with a blood flow rate of 350 mL/min,and heparin 1000 units. There was no documentation as to why the blood flow rates and heparin were different. The dialysis flow rate was not documented.

Patient #28 had orders for a blood flow rate of 300 mL/min, dialysate flow rate of 600 mL/min, and heparin orders of "Load: 2000 units IVP; Hourly 500 units IV."
On 01/22/14 the patient received a dialysis treatment with a blood flow rate of 350 mL/min,and heparin 1000 units. There was no documentation as to why the blood flow rates and heparin were different. The dialysis flow rate was not documented.


E. Patient #1 had orders for "Epogen 4000 units IV" and Heparin "Load: 2000 units IVP; Hourly 500 units IV." On 04/04/14 and 04/07/14, Patient #1 received Epogen and Heparin. There was no documentation of the time the medications were given.

Patient #28 had orders for "Epogen 4000 units IV" and Heparin "Load: 2000 units IVP; Hourly 500 units IV." On 01/20/14 and 01/22/14, Patient #28 received Epogen and Heparin. There was no documentation of the time the medications were given.

During an interview on 04/08/14 at 1:00 PM, Personnel #16 was informed of the above findings and confirmed the findings.

Based on observations, interviews and record reviews the hospital failed to ensure the Director of Dietary Services supervised and maintained the dietary department for the hospital's only kitchen in a responsible manner in that the following was observed during the survey:

1) 1 of 1 bag of chicken enchiladas did not have a date of when they were opened or when they would expire;

2) A Styrofoam drink cup with a cover and straw was sitting on the food preparation (prep) area;

3) 3 of 6 soup bowls were wet and stacked on top of one another;

4) 2 opened buckets of cleaner and a bottle of Fast Foam Degreaser was stored in the opened cabinet under the sink next to the food preparation area; and

5) Personnel #2 hung a wet mop on the wall with the wet mop touching the wall.

Findings included:

During a tour of the facility's kitchen on the afternoon of 4/07/14 with Personnel #1 and Personnel #2 the following was observed:

1) Inside of the kitchen's refrigerator a clear bag of chicken enchiladas was not labeled with a description of the contents and there was no open or expiration date. Personnel #2 confirmed the observation and threw the enchiladas away.

The hospital's Food Storage policy dated 1/05/11 reflected, "...Items which have been opened and are returned to storage shall be covered, labeled and dated..."

2) Upon entry into the kitchen a Styrofoam drink cup with a cover and a straw was sitting on top of the food prep area. Personnel #2 was present and stated it was okay to bring drinks into the food prep area as long as the cup had a cover.

The hospital's Uniform, Hygiene, and Appearance policy dated 1/05/11 reflected, "...Eating and drinking is prohibited in all food production areas..."

3) Personnel #1 separated the stored stacked soup bowls and found 3 soup bowls were wet. Personnel #1 confirmed the bowls were wet.

The hospital's Dish Room Protocol dated 1/05/11 reflected, "...All dishes, utensils, pots and pans are air dried before storage.

4) There were 2 opened buckets of cleaner and a bottle of Fast Foam Degreaser observed stored in the opened cabinet under the sink that was connected to the food preparation area. Personnel #2 said he thought it was okay to store the buckets of cleaner under the sink. He removed the Fast Foam Degreaser from the food preparation area.

The hospital's Storage-Non Food supplies policy dated 1/05/11 reflected, "...Chemical agents, i.e. detergents, cleaning agents, etc., shall be stored in the chemical storage area away from all food supplied. While in use for cleaning purposes all chemical agents, i.e. detergents, cleaning agents, etc., will be kept no closer than six (6) feet from food production areas..."

5) Personnel #2 removed a wet mop from a bucket and hung the mop on the wall with the wet mop touching the wall's surface. Personnel #1 confirmed the observation.

Based on interview and record review the facility failed to include infection control data in 2 of 4 Quality Indicator reports for the year 2013 (3rd and 4th quarters of 2013).

Findings included:


On 4/09/14 at 3:00 PM the Infection Control program was reviewed and revealed the facility was tracking and trending patient community/nosocomial infections for 2013 through April 9, 2014 with follow-up actions and dates of resolution.


The 2013 Monthly Quality Indicator report reflected there was no community or nosocomial infection data documented during the 3rd and 4th quarters.


During an interview on 4/08/14 at 11:30 PM with Personnel #1 he revealed he had worked at the facility since 11/11/13. He stated that Personnel #12 had been responsible for the infection control program beginning 8/01/13. Personnel #1 discovered infection control data was missing during the Governing Board meeting on 1/27/14.

Review of the hospital's Infection Prevention Plan: Scope of Services policy and procedure with a revised date of 1/24/13 reflected, "...Significant infection control data/information shall be disseminated no less than quarterly to the Quality Committee...The Chief Executive Officer, Chief Nursing Officer and medical staff shall be responsible for the following: The hospital-wide quality assessment and performance improvement program and training programs will address programs identified by the ICP [Infection Control Program]..."