HospitalInspections.org

Based on record review, review of the facility's Medical Staff Bylaws and staff interview; the Critical Access Hospital (CAH) failed to maintain an infection control program that included a system for identifying, tracking and analyzing infectious processes and an evaluation of preventative interventions.
This lack of an inclusive infection control program has the potential to effect all patients served at the CAH.

Findings are:

A. A review of the "INFECTION PREVENTION PROGRAM PLAN 2015" revealed, "It is the policy of the (CAH) to provide an infection prevention program for the protection of our patients, visitors, and staff. It is the intent of (the CAH) to prevent infection, and as a second line of defense, to detect any outbreak quickly and to contain it once it has been discovered. It is the goal of (the CAH) Infection Prevention Program to make sure that appropriate equipment, staff education, and resources are available to accomplish these goals..."

"...The Infection Prevention Coordinator shall, in cooperation with the Infection Prevention Committee, have the authority to:
1) Institute procedures and policies that provide a coordinated approach to the study of all hospital infection and identify those which are healthcare associated according to established criteria.
2) Take action necessary to prevent or control the spread of infection within the facility.
3) Orient new employees to (the CAH) policies and procedures including but not limited to hand hygiene, isolation guidelines and proper personal protective equipment, and
4) To foster communication between the Infection Prevention Committee and all other hospital departments and the Medical Staff..."

"...Infection Prevention Committee members are expected to attend the quarterly committee meetings or have an alternate attend.." "...The Infection Prevention Program shall include monitoring and evaluations of:
1) A surveillance system that report healthcare associated infections by patient, service, physician, site, and pathogens.
2) Compliance monitoring to Bloodborne Pathogen Standards.
3) Concerns of department managers, physicians, and employees regarding infection issues.
4) Variance/incident trends of exposures.
5) Concerns of the Infection Prevention Committee, and
6) Issues of new development or trends related to infection prevention and Prevention including breakouts..."

"...The Infection Prevention Program shall include reporting provisions including:
1) Monthly reports to Administration...
2) Quarterly reports to the Infection Prevention Committee... and
3) Annual reports to the Infection Prevention Committee."

B. An interview with the Infection Control Nurse (ICN) on 2/23/16 at 4:00 PM, revealed that the CAH does not maintain a log/tracking system for staff or patient infectious processes. The ICN revealed that there is not a "committee" that meets monthly. The ICN gathers patient names and lab result information (for infections that could be facility acquired) on a monthly basis and provides that information to the clinic's Infection Physician for review. After review, the Infection Physician returns the form to the ICN.
According to the ICN, the last Infection Control report that was provided to the facility's Medical Staff was in June of 2015. The ICN revealed that staff illnesses are reported to the ICN and filed in a notebook, there is no log for that information. The ICN revealed, "To my knowledge, the only communicable disease outbreaks we have a preparedness plan for are EBOLA and Tuberculosis."

C. A review of the Medical Staff Bylaws (revised 2012) revealed, "Infection Control - Be responsible for the surveillance of inadvertent hospital infection potentials the review and analysis of actual infections, the promotion of a preventive and corrective program designed to minimize infection hazards, and the supervision of infection control in all phases of the hospital's activities."

D. An interview with the facility Director of Nurses on 2/24/16 from 8:45-9:00 AM revealed, "If (the ICN) didn't have a log we don't have one. We used to have one, but it must have gotten lost in all the change over in that position. I didn't know we didn't have a preparedness plan for community outbreaks."

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that 5 of 6 outpatient surgical patients (Patients 26, 28, 29, 30 and 31) had documented evidence in heir medical record that a Pre-Anesthetic Risk Evaluation (The physician evaluates/examines the patients current condition including the heart, lungs and review of test results ordered at the time of the history and physical to assure the patient can safely proceed with the procedure scheduled including receiving the anesthesia) had been conducted for the patient by the physician immediately before surgery. This failure has the potential to effect all patients receiving surgical procedures at the CAH. The CAH identified 637 surgical procedures done from July 1, 2014- June 20, 2015.

Findings are:

A. A review of the medical record for Patient 26 revealed the patient was admitted 10/15/15 for a laproscopic cholecystectomy (surgical removal of the gallbladder). Patient 26 received a general anesthesia (medication to sedate them into a medically induced coma which requires support for breathing) for the surgery. On 10/13/15 Physician F completed a History and Physical on Patient 26 at the clinic.

The surgical record for Patient 26 lacked documentation of a a Pre-Anesthetic Risk Evaluation by Physician I (the physician performing the surgery) on 10/15/15.

B. A review of the medical record for Patient 28 revealed the patient was admitted 1/12/16 for a cystocele repair (repair of a bladder prolapse against the vaginal wall). Patient 28 received a general anesthesia for the surgery. On 1/7/16 Physician H completed a History and Physical on Patient 28 at the outpatient clinic.

The surgical record for Patient 28 lacked documentation of a Pre-Anesthetic Risk Evaluation by Physician H (the physician performing the surgery) on 1/12/16.

C. A review of the medical record for Patient 29 revealed the patient was admitted 2/10/16 for a Tonsillectomy and Adenoidectomy (surgeries that remove the tonsils and adenoids). Patient 29 received a general anesthesia for the surgery. On 1/25/16 Physician D completed a History and Physical on Patient 29 at the clinic.

The surgical record for Patient 29 lacked documentation of a Pre-Anesthetic Risk Evaluation by Physician D (the physician performing the surgery) on 2/10/16.

D. A review of the medical record for Patient 30 revealed the patient was admitted 12/18/15 for a redundant prepuce (surgeries that corrects the foreskin following a circumcision). Patient 30 received a general anesthesia for the surgery. On 12/7/15 Physician C completed a History and Physical on Patient 30 at the clinic.

The surgical record for Patient 30 lacked documentation of a Pre-Anesthetic Risk Evaluation by Physician G (the physician performing the surgery) on 12/18/15.

E. A review of the medical record for Patient 31 revealed the patient was admitted 11/11/15 for a Total knee replacement. Patient 31 received a general anesthesia for the surgery. On 11/4/15 Physician C completed a History and Physical on patient 31 at the clinic.

The surgical record for Patient 31 lacked documentation of a Pre-Anesthetic Risk Evaluation by Physician J (the physician performing the surgery) on 11/11/15.

F. An interview with the Director of Nurses on 2/24/16 at 9:00 AM verified the medical records for Patients 26, 28, 29, 30 and 31 lacked evidence of a Pre-Anesthetic Risk Evaluation by the surgeon/physician immediately before the surgeries.

Based on review of contracted services for the Critical Access Hospital (CAH) and staff interview, the CAH failed to have a contract/arrangement with a dentist to provide services for the swing bed patients. This failure has the potential to effect all patients served in the CAH at the swing bed level of care. The CAH identified 100 swing bed admissions from July 1, 2014 - June 20, 2015.

Findings are:

A. A review of the list of contracted services on the form "Product/ Service/ Professional Contracts" revealed no evidence that the CAH had a contract or arrangement with a dentist.

B. An interview with the Administrator on 2/25/16 at 10:50 AM revealed that the previous contract with the dentist had lapsed and the CAH currently does "not have a contract with a dentist".