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Based on observation, interview and document review, the hospital failed to ensure that proper sanitizing agent was used between each patient use for the multi-patient use. This had the potential to affect all patients who required blood glucose readings at the bedside.

Findings include:

The multi-patient use glucometer was being sanitized with alcohol only. The alcohol agent had not been approved by the EPA as an antimicrobial product effective against Mycobacterium tuberculosis, Human HIV-1 and Hepatitis B virus.

During interview with licensed practical nurse (LPN)-E at 8:30 a.m. on 9/5/12, she showed the surveyor the CAH'S glucometer kit that is used for taking patients ' blood sugars. The kit was observed to contain one (1) common glucometer, several alcohol swabs, lancets and glucose testing strips. LPN-E indicated that the staff ' s current practice was to use 70% isopropyl alcohol swabs to clean the glucometer between patient uses. She further stated that the staff will wipe the glucometer with one (1) or two (2) swipes when cleaning the glucometer.

During an interview with registered nurse (RN)-D at 8:45 a.m. on 9/5/12, she verified that the CAH staff was using 70% alcohol swabs to clean the common glucometer between patients.

Review of the manufacturer ' s instructions for the CAH's glucometer (Accu-check inform meter), revealed the cleaning instructions; use a dampened cloth or pre- moistened wipe with one of the following: 1) Water 2) soap 3) 70% (or less) isopropyl alcohol 4) 1:1 dilution of sodium hydrochloride 5) ammonium chloride.

Review of the policy for the Accu-Check Blood Sugar Monitoring dated 10/15/2007, did not include cleaning of the common glucometer between patient uses.

Interview with the director of nursing at 10:15 a.m. on 9/6/12, she verified that the CAH did not have a policy that included the procedure for cleaning the multi-patient use glucometer. She also confirmed that the manufacturer ' s instructions were not the current standards of practice with cleaning the multi-use glucometer from the Centers of Disease Control (CDC) and the Environmental Protection Agency (EPA.)

Based on the certification survey completed on September 6, 2012, the facility was found not in compliance with Life Safety from Fire found at CFR §485.623(d).

Refer to Life Safety Code deficiencies at regulations; K-0011, K-0017, K-0029, K-0033, K-0038, K-0050, K-0052, K-0054, K-0056 and K-0072 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation and staff interview, the hospital failed to maintain a clean and orderly dietary environment. This has the potential of affecting all patients, staff and visitors who eat food prepared in the kitchen.

Findings include:

During the tour of the dietary department at 9:00 a.m. on 9/5/12 with the certified dietary manager (CDM) the following concerns were observed. Three of four metal drawers were found to have paint chipping off leaving a rust and difficult to fully sanitize the surface. One of these drawers contained flatware which was immediately adjacent to this rusty surface. There were four metal cabinets located above a food preparation surface which had chipped paint surface located on the inside shelves. One of the rusty cabinets stored drinking glasses and they were set on top of the rusty shelf. The industrial made can opener had been affixed to a food preparation area and was had been observed to have an accumulation of dark black debris and rust colored blade. It was removed by the facility after being made aware of the debris.

At 9:30 p.m. on 9/5/12 the CDM verified the can opener, rusty cabinets and drawers were old and deteriorating and needed to be refurbished and/or cleaned.

During review of the Nutrition Services Manual Policy with the latest revision July 2012 stipulated: "Sanitary conditions are maintained in the preparation and service of the food served by nutrition service." "To provide proper handling of food, utensils and equipment in the cafeteria to prevent potential food borne illness."

Based on observation, interview and document review, the CAH failed to ensure crash carts that contained emergency drugs were kept locked in a secure area in the hospital's emergency department (ED). This had the potential to affect the availability of emergency medications located in an emergency cart and could affect any patient in need of emergency use medications that are time sensitive for medical emergencies.

Findings include:

Emergency medications located in the ED were not securely stored or monitored to prevent access by unauthorized persons when facility staff was not in the direct location of the emergency rooms.

During a tour of the ED with registered nurse (RN)-C at 11:00 a.m. on 9/5/12, a crash cart was observed in ED room 1, and another crash cart was observed in ED room 2, These rooms were located on a wing away from the nurses ' station and a door between the nursing station and the ED hallway was kept closed. The carts were unlocked but had a breakaway tab in place. The crash carts contained medications including: Epinephrine (often used for shock and cardiac arrest), Narcan (a narcotic used for pain control), Lidocaine (an anesthetic), Amiodarone (used to treat cardiac arrhythmia), Atropine (often used to regulate the heart), and Dopamine (improves nerve conduction). According to interview with RN-C during the tour, she stated the crash cart tabs were to be monitored every shift but could not verify that this was being done.

RN-C and RN-B verified during interview at 11:30 a.m. on 9/5/12, that the crash carts were not always visually supervised and could be accessed by patients or other unauthorized persons in the area. RN-B and C continued to say that the entry doors to the hallway where the two ED rooms were located are left unlocked and accessible to patients and visitors in the area.

During review of the hospital policy for Storage of Medication included: "All medications are maintained in the locked pharmacy or medication room." The medication room is accessed via keyless entry code and pharmacy is accessed via code access and key. It further includes that the medications are no longer kept in the emergency department, except those on the crash carts. Even though the policy indicates that all medications are to be locked, the policy was not clear in regards to the crash carts and the safe storage of medications that they contained.

Based on document review and interview, the facility failed to consistently authenticate, time and or date entries in the medical records for 6 of 21 patients (P4, P5, P6, P7, P8 and P9) in the sample who had their medical records reviewed.

Findings include:

P4's medical record entries did not include the time and date of the practitioner signature on all entries.

P4's medical record was reviewed on 9/5/12. The record indicated the Discharge summary which had been dictated on 6/9/12 was signed by the practitioner however, the dated and time of day was not documented as required. The lab report of 6/6/12 was signed but no date or time of day was documented by the practitioner.

P5's medical record entries did not include the time and date of the practitioner signature on all entries.

P5's medical record contained a lab report with a collection date 4/12/12. This report had not been signed, dated or timed by the practitioner. The patient's ultrasound report of 4/11/12 had the practitioner signature but the time and date was not documented.


P6's medical record entries did not include the date or the time of day of the practitioner signatures on all entries.

P6's History and Physical which was dictated on 5/7/2012 was signed by the practitioner but the date or time of day was not documented.
In addition, the diagnostic imaging report, dictated on 5/7/12 did not have a signature of the practitioner nor date or time. The final copy of the lab results of a TSH (Thyroid Stimulating Hormones) dated 5/8/12 did not have a signature, the date, or time of when it was reviewed by the practitioner.

P7's medical record reviewed on 9/5/12 did not always include the signature, date or time of day on the all of the entries.

P7's medical record was reviewed on 9/15/12. The record reflected the patients discharge summary dictated on 3/14/12 was signed and dated by the practitioner; however, the time of day was not documented as required.
P7's lab report on Pre-albumin level completed on 3/13/12 was not documented as signed, dated or timed by the practitioner.
P7's lab results collected on 3/9/12 were signed by the practitioner however; neither the date nor time of the day was documented.

P8 ' s medical records had been reviewed and several forms lacked times and/or date of the practitioners signing the form.

P8 ' s Admission History and Physical Report dictated on 05/10/2012 had the physician ' s signature however; no date or time was completed even though the form has a designated entry to complete this information. P8 ' s Discharge Summary with a dictation date of 05/15/2012 had the physician ' s signature however, did not include the date or time of authentication. P8 had blood drawn with a collection date of 5/15/2012 for blood complete blood count (CBC) and there was no physician signature, date or time on the lab form sent to the practitioner.

P9's medical record was reviewed on 9/15/12. The record reflected that all the entries did not include the time and date of the practitioner's signature.

P9 ' s Computed Tomography report which was dictated on 4/27/12 did not have the date or time of day of practitioner's signature documented. The History and Physical report dictated on 4/27/12 was signed and dated by the practitioner however, the record lacked documentation as to the time of day of the signature.

Interview with the CAH Medical Records person and the CEO (chief executive officer) at 11:00 a.m. on 9/6/12 indicated the facility did not have a specific written policy regarding the completion and accuracy of physician signatures, dates and times in the patient medical record. They both verified that the CAH should have a specific policy in place so that the physicians would be accountable for the completion of their signatures, dates and times on the physician orders, labs and history and physicals reports.

Based on interview and record review, the Critical Access Hospital (CAH) was found not to be in compliance with the Conditions of Participation for Surgical Services under (CFR §485.639) due to failure to follow manufacturer's recommendations, develop policy/procedures which addressed fire risk reduction measures which are appropriate and then verify by documenting in the medical record that the proper procedures were followed related to the use of alcohol based skin preparation in anesthetizing locations to prevent the risk of surgical fires. This practice was evident for 3 of 3 patients (P1, P2 and P3) reviewed in the sample that required an alcohol based skin preparation agent and also would include all surgical patients who would need the use of an alcohol based skin preparation agent. This deficient practice had the potential to affect all patients who underwent surgery and required usage of an alcohol based skin prep.

Findings include:

The CAH did not fully develop 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 an alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken as part of a systemic approach by the CAH to preventing surgery related fires.

On 9/5/12 at 10:30 a.m. an interview was conducted with registered nurse (RN)-A (the circulating nurse manager) regarding the facility policy/procedure for use of alcohol based skin preparation. RN-A indicated that the CAH had been using alcohol based skin preps for surgical procedures. She further indicated that the staff had allowed the alcohol based prep to dry for approximately one minute. RN-A verified that the surgical staff have never timed (noted the time on the clock from the end of application of the alcohol based skin preparation to the time the clock had gone one minute) the dry time of the alcohol based prep. Although the staff indicated they routinely checked to assure the alcohol had completely dried, the CAH staff had not timed or documented in the patient record verifying that appropriate procedures for the dry time were followed, prior to the draping of the surgical procedure.

During record review it was noted that alcohol based skin preparation had been utilized during three (3) surgeries for P1, P2 and P3 as follows: P1 on 3/8/12, had a Laparoscopic cholecystectomy P2 on 7/20/12 had an appendectomy and P3 on 8/27/12 had a Cesarean Section. Review of the Nursing Operative Report for all three (3) records confirmed that alcohol skin preparation had been utilized as indicated by the surgical staff. No documentation was evident in each medical record to indicate the alcohol based skin prep had been allowed to dry for three minutes and/or the appropriate procedure implemented.

The Albany Area Hospital and Medical Center CAH, skin preparation policy of the operative site indicated; ChloraPrep solution should be allowed to thoroughly dry before incision or the use of cautery. It was noted that this current policy did not include a safe dry time after the application of the alcohol skin preparation or other information to reduce the associated risk of fire or need to document the implementation of these policies and procedures in the medical record.

Review of the Manufacturer's instructions for the use of ChloraPrep included: to reduce risk of fire, do not drape or use ignition source until solution is completely dry (minimum of three (3) minutes) on hairless skin; up to one (1) hour in hair. Drying time for dry and moist surgical sites is approximately three (3) minutes.

In an interview with RN-A (circulating nurse) at 10:00 a.m. on 9/6/12, she confirmed she had not been aware of the recommended dry time for the use of the alcohol based surgical preps. She further confirmed that the staff had been allowing the ChloraPrep to dry for about a minute before draping the patient for surgery.

The Director of Nursing (DON) was interviewed at 11:15 a.m. on 9/6/12, and confirmed there was no documentation evident in the patient records regarding drying of the alcohol based skin prep prior to draping of the patient.