HospitalInspections.org

C-1008
Based on record reviews and staff interviews, the Critical Access Hospital, (CAH), failed to assure the policies and procedures of the CAH were reviewed biennially by a group of professional personnel of the CAH. This failed practice had the potential to affect all patients of the CAH. In the fiscal year of 2021 the CAH had 125 acute care hospital days, 66 observation days, 28.33 Emergency room visits per month, 921 swing bed patient days and an average total of 445.42 outpatient visits per month.

Findings are:

Record review of the following policies revealed:
The Admission Policy for Swing bed was last reviewed 5/2019.
Documentation for Skilled Swing Bed showed an effective date of 5/20/2014 but no review date.
Discharging Swing Bed Patient Policy was last reviewed in 5/2019.
Cardiac Rehab Program Policies revealed a top sheet on the binder of polices dated 2011.
Infection Prevention and Control Plan last revised 8/2008
Infection Control section I Management Surveillance Procedure last revised 4/2008.
Genoa Medical Facilities Quality Plan last review date 5/20/2018.
Water Management Program Plant Operations (Legionella) Committee last approval 5/31/2018.
Cleaning and Storage of Flexible Scopes - To be reviewed date of 3/20
Dismissal Following Ambulatory Surgery Stay (No date)
Post-Operative Care - To be reviewed date 3/20
Routine Pre-operative orders (No Date)
Sterilization - To be reviewed 7/19
Pre-op Evacuation - To be reviewed 3/17
Surgical Hand Scrub (no date)
Anesthesia Care Policy (4/28/16)
Cautery Pad Placement - Revised 9/99 (No Review Date)
Safe us of flammable germicides and antiseptics - No date
Conscious sedation policy - No date
Sanitizing Operating Room Policy (No Date)
Cardiac Arrest in the Operating Room - No Date
Standards for Nurse Anesthesia Practice - (6/30/19)
Documenting Anesthesia Care: Practice and Policy Considerations - (6/3019)
Malignant Hyperthermia - (1/22)
Dispensing Out Patient Medication - No Date
Medication Procurement - No Date
Adverse Reactions - review date 6/16
Drug Recalls - No Date
Medication Errors and Drug Reactions - No Date
RCRA Hazardous Waste Disposal - review date 3/18
Medication Disposition - review date 3/18

Interview with Director of Nursing on 3/17/2022 at 1:00 PM confirmed that the policies of the CAH were in need of review biannually.

Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance (PM) according to manufacturer's guidelines for 4 of 17 sampled pieces of medical equipment. This failed practice had the potential to effect all patients of the CAH. The CAH had 125 total acute care patient days, 921 swing bed patient days, 2096 physical therapy visits and 445.42 average total outpatient visits per month in Fiscal Year 2021.

Findings are:

Record review of the Agiliti Biomed 360 Agreement dated 12/2/21 and Agiliti spreadsheet of facility assets, reveals that there was no Agiliti Asset ID number for the E. Stim. Machine, game ready machine or Airdyne bike nor was there a sticker indicating last inspected dated. Additionally, there was no last inspected date listed for the gas module on the anesthesia cart but an asset number was written as 1093380 which could not be found on the Agiliti spreadsheet.

Observation of the Physical Therapy Department on 3/14/2022 at 3:00 PM revealed an E-Stim. Machine (a machine that is used to strengthen muscles, block pain signals, and improve blood circulation through electrical stimulation and a game ready machine (active compression and cold therapy device to promote recovery from injury) did not have biomedical sticker to indicate preventive maintenance program.

Interview with Physical Therapist on 3/14/2022 at 3:00 pm confirmed that there was no biomedical sticker on the E Stim. Machine or game ready machine.

Observation of the Operating Room Department on 3/15/2022 at 2:30 PM revealed that the Gas Module on the anesthesia cart, (a module used to measure the end title CO2), did not have biomedical sticker present to indicate preventative maintenance program.
Interview with Operating Room Nurse on 3/15/22 at 2:30 PM confirmed that there was no biomedical sticker on the gas module on the anesthesia cart.

Observation of cardiac rehab area on 3/15/22 at 8:30 AM revealed an Airdyne Bike (a cardiac machine that is powered by a huge fan that creates wind resistance as you pedal), revealed there was no biomedical sticker on it indicating no preventative maintenance for this item.

Interview with the cardiac rehab nurse on 3/15/22 at 8:35 AM confirmed that there was no sticker on this piece of equipment.

Based on record review and staff interview, the facility failed to provide re-appointment/credentialing verification for three (3) of seven (7) Medical Staff files as required per medical staff by laws every two years. Facility medical staff roster included 52 credentialed providers at time of survey. Facility census was 1 (one) patient. The 3 (three) files were last re-credentialed with final approval March 2019.


Findings are:

A. Review of Medical Staff Bylaws for Genoa Community Hospital last revised in 2015, noted in Section 3. Duration of Appointment - Each regular appointment or reappointment to the Medical Staff and each grant of privileges will be for a period of two (2) years from appointment date of reappointment date, or as soon as thereafter as the Board considers reappointment of Medical Staff, unless earlier terminated, suspended, or limited in accordance with these Bylaws.

Governing Body and Medical Staff meeting minutes reviewed for the past 7 (seven) months August 2021 - February 2022 revealed that the appointment/reappointment process was never reviewed, mentioned or discussed regarding approval candidates for appointments/re-appointments. This practice affected all the 52 credentialed providers of the facility.

B. Medical Staff (MS) - D - consulting surgeon initially applied to medical staff in fall 2018. An application and approval was completed March 21, 2019 for both Medical Staff and Governing Board Approval with Corresponding signatures. MS - D was providing surgery services to out patients January 19, 2022 and February 16,2022. No patients were scheduled for out patient procedures the week of survey March 16, 2022, but would of been provided by MS- D if scheduled. MS- D also had privileges approved in March 2019 to provide appendectomy and cholecystectomy, however the facility did not have the equipment, staffing, trained staff or anesthesia equipment to provide full surgical procedures.

MS - D current credential file from March 2019 appointment had expired information for professional license (10/2/2020), expired DEA (Drug Enforcement Administration) license (7/31/2020), Liability Insurance expired 1/1/2020.
The re-credentialing was past due by one year, as was due to be completed and through the approvals of Medical staff and Governing Body by March 2021.

C. Medical Staff (MS) - A - APRN/CRNA (Advanced Practice Registered Nurse/Certified Registered Nurse Anesthetist) had provided Anesthesia Services for January 19, 2022 for two patients receiving outpatient procedures. MS - A credential file contained re-appointment March 21, 2019. The Re-Credentialing was past due by one year, as was due to be completed and through the approvals of Medical staff and Governing Body by March 2021. Credential file information for Liability insurance expired 12/31/2019 and expired license for APRN/CRNA from October 2020.

D. Medical Staff (MS) -E - a consulting ARPN for out patient clinic services, was initially appointed in 2015 and reappointed March 2019. The current credential file contained expired License for APRN,RN, Expired DEA license 8/30/2020 and expired liability insurance of 1/1/2020.

Interview with Staff member F on 3/16/2022 at 12:45pm revealed the credential files and approval process had no additional information or files available for MS- D, A and E, and the Governing Body and Medical Staff meeting minutes contained no information for review/approval of MS Candidates for the past several years.

Based on med observation, policy and procedure review and interview the Critical Access Hospital (CAH) failed to ensure that outdated drugs and biologicals were not available in 6 of the 7 areas observed for patient use. These failed practices have the potential to affect all patients of the CAH. In the fiscal year of 2021 the CAH had 125 acute care hospital days, 66 observation days, 28.33 Emergency room visits per month, 921 swing bed patient days and an average total of 445.42 outpatient visits per month.

Findings are:

Observation and tour on 3/15/2022 at 3:15 PM revealed the following outdated medications and biologicals:

Med Room
3 vials- Teflaro 600mg vial Expired 3/2021

IV Room:
2 bags- Heparin 25000units/250ml bag Expired 12/2020
21bags- Heparin 25000units/250ml bag Expired 12/2020
3 - IV 18ga (1.16 in) catheters Expired 9/30/2020
10- IV 18ga (1.16 in) catheters Expired 2/28/2022
17- IV 16ga (1.16in) catheters Expired 11/30/2019

Anesthesia Cart:
1 vial- Labetalol 100mg/20ml Expired 2/1/2022
1 box- Glucagon 1mg Expired 1/2022
1 vial- Phenylephrine 10mg/ml (1ml vial) Expired 9/2021
9- 25ga Needles Expired 7/31/2021

Pediatric Cart:
1 bag- 5% Dextrose NS 1000ml Expired 2/2021
1 bag- Normal Saline 1000ml Expired 6/2021
1 bag- Normal Saline 500ml Expired 4/2021
2- Bougie Expired 6/19/2021
1 - 10french catheter Expired 5/31/2021
3- Pediatric Pulse oximetry Expired 11/1/2020
1 - Intubating stylet Expired 1/2022

Procedure Room:
6- E-Swab Expired 7/31/2021
2- Microorganism Collection and Transport System (lab swab) Expired 11/6/2021

Lab:
5- Microorganism Collection and Transport System Expired 11/6/2021

Review of policy Product Management within Pharmacy revised March 8, 2021 revealed pharmacy technician is responsible for checking their assigned areas for outdated medication. No policy supplied for process of outdated supply management.

Interview with Director of Nursing (D.O.N.) on 3/15/2022 at 3:00PM confirmed that medications and supplies listed are outdated. D.O.N also confirmed that the LPN was responsible for checking outdates of medications and LPN and lab staff are responsible for checking outdates of supplies.

C - 1104
Based on record review and interview, the Critical Access Hospital (CAH) failed to assure the medical records are complete, accurately documented and systematically organized. This failed practice had the potential to affect all patients of the CAH. In fiscal year 2021 the CAH had 125 acute care hospital days, 66 observation days, 28.33 Emergency room visits per month, 921 swing bed patient days and an average total of 445.42 outpatient visits per month.

Findings are:

Record review revealed incomplete and accurate documentation; advanced directives, informed consents, care plans and history and physicals:

Record review of sample patient #40 indicated no consent form.
Record review of sample patient #13 indicated consents and advanced directive were on file in the long term care record, no acute care consents.
Record review of sample patient #11 indicated no advanced directive or no care plan.
Record review of sample patient #1 advanced directive on file in long term care record. No consent form or inpatient care plan.
Record review of sample patient #15 indicated no advanced directive on file.
Record review of sample patient #8 indicated a blank consent form and blank advanced directive.
Record review of sample patient #34 advanced directive noted as verbal - not checked as to whether living will, durable power of attorney for Health or I have not executed either a living will or durable power of attorney for health care at this time.
Record review of sample patient #35 indicated advanced directives not signed
Record review of sample patient #5 indicated no inpatient care plans
Record review of sample patient #2 indicated no consent form.
Record review of sample patient #19 indicated LTC consent form.
Record review of sample patient #7 indicated verbal consent, no date or time.
Record review of sample patient #26 No advanced directive; no date and time on surgical consents, no History and Physical.
Record review of sample patient #28 indicated no advanced directive, no history and physical.
Record review of sample patient #29 indicated no advanced directive, no history and physical.
Record review of sample patient #30 indicated no advanced directive, no history and physical.
Review of sample patient #31 indicated no advanced directive.

Interview with Medical Records Director on 3/15/22 10:00 AM confirmed "we have nurses scanning in forms but they don't pay attention to where it should go in the medical record". Also confirmed that there is not a process for making sure the chart is complete with all documents.

Based on record review, observation and interview of manufactures instructions the Critical Access Hospital (CAH) failed to (A) train personnel on manual endoscope reprocessing, (B) follow policy and procedure for pre-operative history and physical, post-operative care, discharge orders and responsible adult, (C) to ensure a Registered Nurses completed circulator duties, (D) and to keep a log of endoscope processing and patient use to track after infectious outbreaks per the Centers of Disease Control (CDC) recommendations. This failure of practice had the potential to affect all surgical patients at the CAH. There was an average of 2 surgical cases per month for fiscal year 2021.

Findings are:

A.

Review of Licensed Practical Nurse (LPN) education for Surgery Department revealed education on endoscope care and cleaning dated 2/17/2022. The training reviewed lacked manufacture instructions on enzyme cleaner and water ratio.

Review of manufacture instructions of enzyme used revealed that 1 ounce of enzyme liquid concentrate per gallon of water. further review of onsite enzyme revealed expiration date of 12/2015.

Interview of Licensed Practical Nurse (LPN) on 3/15/2021 at 2:29 PM revealed that annual competency for endoscope processing is not completed .Licensed Practical Nurse (LPN) confirmed that "several years ago" was the last time training was received on the automatic endoscope preprocessor from the company representative. Licensed Practical Nurse (LPN) confirms that the endoscope manual cleaning process is performed from "knowledge from prior employment" Licensed Practical Nurse (LPN) stated does not measure amount of water added to enzyme cleaner.

Interview of LPN on 3/15/2021 at 2:29 PM confirmed that the endoscope manual cleaning process is performed from "knowledge from prior employment" only.

Interview with Director of Nursing (D.O.N.) on 3/16/2022 at 10:54 AM confirmed the enzyme containers used were expired 12/2015.

B.

Review of medical record # 26 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 2/16/2022 under IV sedation. Review of the entire medical record revealed a lack of pre-operative history and physical, lack of recovery room Post Anesthesia Care Unit (PACU) score, dismissal order from a physician and lacked documentation of discharge to responsible adult.

Review of medical record # 27 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 1/19/22 under IV sedation. Review of the entire medical record revealed a lack of pre-operative history and physical, lack of recovery room PACU score, dismissal order from a physician and lacked documentation of discharge to responsible adult.

Review of medical record # 28 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy and esophagogastroduodenoscopy (EGD) on 7/21/21 under IV sedation. Review of the entire medical record revealed a lack of pre-operative history and physical, lack of recovery room PACU score, dismissal order from a physician and lacked documentation of discharge to responsible adult.

Review of medical record # 29 on 3/16/2022 at 2:00 PM revealed surgical procedure of EGD on 7/21/21 under IV sedation. Review of the entire medical record revealed a lack of pre-operative history and physical, lack of recovery room PACU score, dismissal order from a physician and lacked documentation of discharge to responsible adult.

Review of medical record # 30 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 2/6/22 under IV sedation. Review of the entire medical record revealed a lack of pre-operative history and physical, lack of recovery room PACU score and dismissal order from a physician.

Review of medical record # 31 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 1/19/22 under IV sedation. Review of the entire medical record revealed a pre-operative history and physical dated 12/29/21 (over 7 days per policy), lack of recovery room PACU score, dismissal order from a physician.

Review of policy and procedure Routine Pre-Operative Orders (no date) revealed that a history and physical completed by physician within 7 days or interim history and physical if longer.

Review of policy and procedure Post-Operative Care review date 3/2020 revealed the patient must have a 9 PACU score before dismissal from the PACU.

Review of policy and procedure Dismissal Following Ambulatory Surgery Stay (no date) revealed dismissal criteria will include a discharge order by physician and a responsible adult to accompany patient home. Patient will not be discharged to drive themselves home.

Interview with Health Information Management Specialist on 3/16/2022 at 2:00 PM confirmed that medical records reviewed lacked the above information.

C.

Review of medical record patient # 26 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 2/16/2022 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of medical record patient # 27 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 1/19/2022 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of medical record patient # 28 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy and EGD on 7/21/2021 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of medical record patient # 29 on 3/16/2022 at 2:00 PM revealed surgical procedure of EGD on 7/21/2021 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of medical record patient # 30 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 2/16/2022 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of medical record patient # 31 on 3/16/2022 at 2:00 PM revealed surgical procedure of Colonoscopy on 1/19/2022 under IV sedation. Review of the intra-operative record revealed LPN as circulating nurse.

Review of job description titled Circulating Nurse reviewed 5/9/2020 revealed required Registered Nurse license required.

Interview with Director of Nursing (D.O.N.) on 3/15/2022 at 2:47 PM confirmed LPN performed in circulator role in operating room.

D.

Review of the CDC recommendations that each endoscope has a unique identifier to facilitate tracking. Tracking should include the ability to determine when specific endoscopes were used for specific patients, loaned to other units or facilities, reprocessed, or repaired. Tracking is also essential for responding to device or product recalls.

Observation of endoscopes and storage area with D.O.N on 3/15/2022 at 2:47 PM revealed that endoscopes were not uniquely identified and CAH was not keeping a log of endoscope processing and patient use to help facilitate tracking of endoscopes if needed for infectious outbreak.

Interview with LPN on 3/16/2022 at 9:15 AM confirmed that a log of endoscope processing and patient use to track for infectious outbreaks is not being completed.

Based on record review and staff interviews, the facility failed to include all services affecting patient health and safety in quality assurance and these services were not being evaluated by the facility. This failed practice had the potential to affect all patients of the facility. The facility had 125 acute care hospital days for fiscal year 2021 and 921 swing bed patient days for fiscal year 2021.

Findings are:

Record review of facility Quality Assurance (QA) 2022 Calendar, failed to include therapy services, Cardiac Rehab and Pulmonary Rehab.

Interview with Physical Therapist on 3/14/22 at 3:00 PM confirmed that Physical Therapy, Occupational Therapy and Speech Therapy are not participating in QA studies or evaluations.

Record review of "Genoa Medical Facilities Quality Plan" policy last review date 5/20/2018, stated Continuous quality improvement efforts will include all services and disciplines.

Interview with Assistant Director of Nursing (ADON) on 3/15/22 at 2:00 PM, confirmed that Cardiac Rehab and Pulmonary Rehab are not participating in QA studies or evaluations.

Based on record review and staff interview, the facility lacked a swing bed policy that covered transferring or discharging a resident, a notice before transfer, timing of the notice, contents of the notice, orientation for transfer or discharge and notice in advance of facility closure. This failed practice had the potential to affect all swing bed residents. The facility had 921 swing bed resident days for fiscal year 2021.

Findings are:

Record review of the facility's policies "Discharging Swing Bed Residents" last reviewed 5/2019 by facility and "Documentation for Skilled Swing Bed" effective date 5/2014, revealed the policies were missing the information related to: transfer and discharge rights, notice before transfer, timing of the notice, contents of the notice and documentation in the resident's medical record.

Interview with Director of Nursing (DON) on 3/15/2022 at 11:00 AM confirmed that the facility lacked a policy related to: transfer and discharge rights, notice before transfer, timing of the notice, contents of the notice and documentation in the resident's medical record.

Based on record review and staff interview, the facility failed to complete comprehensive assessments and lacked comprehensive care plans on 2 of 5 swing bed residents. This failed practice had the potential to affect all swing bed residents. The facility had 921 swing bed resident days for fiscal year 2021.

Findings are:

A. Interview with Director of Nursing (DON) on 3/15/22, DON stated, "Charge nurse does the comprehensive assessment." "Care plan updated weekly."

Record review of resident #34 admitted 12/23/21-2/17/22, revealed that the comprehensive assessment and comprehensive care plan were not completed and not present in electronic medical chart.

Interview with the Director of Nursing (DON) on 3/17/2022 at 11:00 AM, DON stated, "CEO said that the daily assessments take the place of the comprehensive assessment."

B. Interview with Director of Nursing (DON) on 3/15/22, DON stated, "Charge nurse does the comprehensive assessment." "Care plan updated weekly."

Record review of resident #35 admitted 12/17/21-2//22, revealed that the comprehensive assessment and comprehensive care plan were not completed and not present in electronic medical chart.

Interview with the Director of Nursing (DON) on 3/17/2022 at 11:00 AM, DON stated, "CEO said that the daily assessments take the place of the comprehensive assessment."

Based on staff interview and record review, the facility failed to have a policy regarding Dental services. This failed practice had the potential to affect all swing bed residents. The facility had 921 swing bed resident days for fiscal year 2021.

Findings are:

Interview with Social Worker (SW) on 3/15/22 at 11:00 AM, SW stated when asked about a policy and procedure identifying circumstances when the loss or damage of a swing bed patient's dentures is the facility's responsibility, "No, but I know we have to replace them."

Record review of facility's Swing Bed policies, confirmed the lack of Dental services including the facility assisting residents in obtaining routine and 24 hour emergency dental care and identifying circumstances when the loss or damage of denture is the facility' responsibility.