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90 SWIFTWATER RD

WOODSVILLE, NH 03785

RECORDS SYSTEM

Tag No.: C1104

Based on interview and record review, it was determined that the Critical Access Hospital failed to ensure that all medical records were complete for 6 of 26 outpatient records reviewed (Patient #23, #24, #32, #36, #33 and #35).

Findings include:

Review on 8/11/22 of the facility's policy titled Cottage Hospital Medical Staff Rules and Regulations, adopted on 10/27/2021 states:
" ...E. The medical record must contain complete information/documentation regarding medical history, assessment of the health status and health care needs of the patient episode, disposition, and instructions to the patient ..."


27714

Review on 8/10/22 of Patient #23's and Patient #24's pulmonary function test procedure intrepretation revealed that there was no date of service.

Interview on 8/10/22 with Staff G (Respiratory Therapist) confirmed the above findings for Patient #23 and Patient #24.

Review on 8/10/22 of Patient #32's electonic medical record revealed Patient #32 had and operative procedure on 5/4/22. Patient #30's history and physical prior to the procedure was dated 3/28/22.

Review on 8/10/22 of patient #36's electronic medical recored revealed Patient #36 had an operative procedure on 8/1/22. Patient #36's history and physical prior to the procedure was dated 4/1/22.

Review on 8/10/22 of Patient #33's medical record revealed Patient #33 had an operative procedure on 5/11/22. Further review revelaed there was no evidence of an operative note by the provider perfoming the procedure.

Review on 8/10/22 of Patient #35's electronic medical record revealed that Patient #35 had an opertative procedure on 7/7/22. Further review revealed there was no note that Patient #35 met discharge criteria prior to discharge.

Interview on 8/10/22 with Staff H (Registered Nurse) confirmed the above findings for Patient #32, #36, #33, and #35. Staff H also confirmed that the history and physicals for Patient #32 and Patient #36 were performed greater than 30 days prior to the operative procedures.

INFECTION PREVENT & CONTROL POLICIES

Tag No.: C1206

Based on record review, observation, and interview, it was determined that the Critical Access Hospital (CAH) failed to employ methods for cleaning and disinfecting equipment to prevent and control the transmission of infections within the CAH in 4 out of 8 departments serving patients that disinfected equipment.

Findings include:

Outpatient Rehabilitation Department:

Observation on 8/9/2022 at approximately 1:10 p.m. of the outpatient rehabilitation department revealed parellel bar therapy equipment contained wooden surfaces with worn varnish with exposed porous wooden surfaces.

Interview on 8/9/2022 at approximately 1:10 p.m. with Staff D (Physical Therapist) confirmed the above finding. Interview further revealed that the wooden parallel bars were cleaned and disinfected with Sani-Cloth AF3 Germicide Disposable Wipes "gray top."

Review on 8/10/2022 of the manufacturer instructions titled "Technical Data Bulletin Sani-Cloth AF3 Germicidal Disposable Wipe," dated 2017, revealed the following: "Use on hard, nonporous surfaces and equipment."

Interview on 8/10/22 at approximately 11:50 a.m. with Staff A (Director of Quality) confirmed the above finding.

Outpatient Orthopedic Department:

Observation on 8/9/2022 at approximately 3:05 p.m. of the outpatient orthopedic department revealed a desk in the patient care hallway where one of the desk's drawers contained a central sterile container and ezymatic cleaner spray. Further observation revealed that the drawer was unlocked, opened directly over a rug floor, and contained stains consistant with the enzymatic cleaner on the drawer surfaces.

Interview on 8/9/2022 at approximately 3:05 p.m. with Staff B (Clinical Supervisor - Orthopedic Clinic) revealed that the process for storing and preparing dirty utility items for reprocessing included transporting dirty instruments from patient rooms to a desk drawer over a rug floor in the patient care hallway containing a central sterile container and enzymatic cleaner spray. Interview further revealed that dirty equipment was prepared in the drawer with enzymatic cleaning spray into an open container within the drawer without barrier protection inside of the drawer.

Central Sterile Department:

Review on 8/9/2022 of the central sterile department's immediate use steam sterilization records from 6/1/2022 through 8/8/2022 revealed that immediate use sterilizer was used to sterilize endoscope suction cleaning adapters using an exposure time of 4 minutes for 21 out of 21 sterilization runs.

Review on 8/10/2022 of the endoscope suction cleaning adapter's manufacturer's instructions titled "Olympus CF-HQ190L/I Reprocessing Manual" revealed the following: "Chapter 3" Compatible Reprocessing Methods and Chemical Agents...Table 3.1 steam sterilization (autoclaving) compatible...the accessories listed as compatible with steam sterlization in Table 3.1 can be sterilized by steam within parameters given in Table 3.4...Table3.4 exposure time 5 minutes."

Interview on 8/10/2022 at approximately 8:40am with Staff A (Director of Quality) and Staff C (Central Supply Technician) confirmed the above findings.

Radiology Department:

Observation on 8/10/2022 at approximately 8:00am of the radioology department revealed a trophon EPR used to high level disinfect validated ulstrasound probes.

Review on 8/10/2022 of the radiology department's Trophon2 High Level Disinfection Log from January 2022 through July 2022 revealed that the CAH failed to consistently document the results of chemical indicators to validate high level disinfection when using the trophon EPR.

Review on 8/10/2022 of the trophon EPR User Manual, dated 6/2017, revealed the following: "...C2.6 Removing the Probe...3. Wearing clean gloves, immediately remove the used Chemical Indicator from the trophon and verify the colour change against the chart on the Chemical Indicator carton. Record the result using the printer or logbook accessories if required."

Interview on 8/10/2022 at approximately 10:12am with Staff E (Radiology Director) confirmed the above findings. Interview further revealed that the process for documenting the results of chemical indicators from the trophon EPR is to verify and document the chemical indicator result in the Trophon2 High Level Disinfection Log.