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Based on observation, interview and document review, the critical access hospital (CAH) failed to store toxic cleaning products, soiled surgical instruments and biohazard products in a secure location.This practice had the potential to affect patients and the public that were in the facility.

Findings include:

During a tour of the nursing unit on 12/8/14 at 11:00 a.m., observations were made of chemical cleaners in an unlocked dirty utility room. The chemical cleaners in the dirty utility room were stored in a cabinet under the counter. The cleaning agents included; Germicidal Bowl Cleaner, Re-Juv-Nal, and QT-TB, (all disinfectants,deodorizers, sanitizers and enzymatic cleaners). All cleaners were labeled "Keep out of reach of children". Further observations were made of a plastic tub that contained used surgical instruments on the counter as well as a hazardous waste container that contained a used IV bag that contained blood products. The soiled utility room did not have a lock on the door and it was located near patient rooms. The room was out of view from the nurses' station.

Review of the The Material Safety Data Sheets (MSDS) for the cleaning agents indicated, "Precautions: Handling & Storing: rapidly causes chemical burns and to wear goggles and gloves when handling. The MSDS further included the chemical agents were toxic if ingested.

Interview with RN-C on 12/11/14 at 9:00 a.m., confirmed the utility room was unlocked at all times and that staff were not always available to supervise the room. RN-C also confirmed the above cleaning agents and hazardous waste products were stored in the utility room. She stated the soiled surgical instruments were stored in the utility room so they could be autoclaved.

Based on interview and document review, the CAH (Critical Access Hospital) failed to ensure the infection control program was being implemented related to ongoing monitoring and trending of infection rates from the surveillance program according to the established policies. This practice had the potential to affect all patients who were treated at the CAH.

Findings included:

On 12/9/14, at 11:00 a.m. registered nurse (RN)-A stated on January 1, 2014 at the time the affiliation with Ridge Medical Center was implemented, the CAH stopped tracking and trending infections/communicable diseases as the CAH thought the infection control preventionist at Ridgeview Medical Center was completing the infection logs, and completing the tracking, trending and analysis of infections for Ridgeview Sibley Medical Center. RN-A verified there were no infection logs completed for the CAH since 2013. The CAH was unable to provide documentation of infections that included; hospital acquired infections, signs and symptoms of infections that were related to the admission diagnosis, signs and symptoms of infection during their hospital stay, type of infection, culture sensitivities, and antibiotics used.

Review of the Infection Prevention/Control Policy last reviewed on 7/30/2013, identified the following " Activities: Infection Prevention/Control activities include the following:

1) Monitoring and evaluation of key performance aspects of infection control surveillance, prevention and management:
·Healthcare Associated Infections (HAI's) in special care units
·Class 1 post-op [post-operative] wound infections
·Class 2 post-op [post-operative] wound infections
·Device related infections
·Antibiotic- resistant organisms
·HAI'sTB [tuberculosis]
·Other communicable diseases
·Employee health trends
·Postoperative pneumonia
·Postpartum infections

2) Continuous collecting and/or screening data to identify isolated incidents or potential infectious outbreaks. Program Elements; 1) Review of positive cultures. All positive cultures are investigated and categorized . 2) Interaction with performance improvement programs; the link between performance improvement and infection control activities is informational gathering and clinical analysis.

On 12/11/14 at 3:55 p.m. RN-A-confirmed the CAH had not followed its infection control policy for completing surveillance, monitoring, tracking, trending, investigating and completing an analysis of infections at Ridgeview Sibley Medical Center.

Based on interview and document review the critical access hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated in the hospitals quality improvement program for the following services; infection control, dietary, organ tissue, eye procurement and all contracted patient care services. This had the potential to affect all current and future patients of the CAH.
Findings include:

The compliance specialist (CS)-A, administrator and registered nurse (RN)-A were interviewed on 12/10/14, at 1:00 p.m. and confirmed the CAH did not have a quality assurance/ performance improvement plan in place for the following identified service areas: infection control, dietary services and organ, tissue and eye procurement. In addition the CS-A confirmed there were no quality assurance/ performance improvement plans in place for any contracted patient care services, some of which included: radiology and imaging diagnostic services, food preparation, and sleep study. Further interview with the administrator verified the above contracted services did not have a quality assurance program in place.