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Based on observation, review of National Fire Protection Association (NFPA) 1 standards and interview, it was determined the facility failed to ensure that the Critical Access Hospital (CAH) was maintained in a manner to ensure the safety well-being of patients in that one of two fire barrier walls was not sealed with fire-proof sealant adjacent to room 313. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 1, 12.9.6.2 where penetrations for conduits that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, shall be protected by a system or material capable of restricting the transfer of smoke.
B. Observations on 12/3/19 at 10:30 AM adjacent to Room Number 313 showed one of two fire barrier walls with tan paper inserted inside of a 6" conduit with one penetrating white electrical wire.
C. The above finding in "B" was verified 12/3/19 at 10:35 PM by the Maintenance Supervisor.


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Based on observation and interview, the facility failed to arrange their storage in a manner which maintained the safety of patients in that there was the presence of combustible items (television, framed pictures, computer monitors, etc.) stored in one of one electrical room. The failed practice had the potential to affect all patients and staff in that the risk of a fire in the electrical room was greatly increased due to the presence of combustible items stored in the electrical room, and a fire in such a location could potentially disrupt the facility's Life Safety electrical system from functioning. Findings follow:

A. Observation on 12/3/19 at 10:00 AM of the electrical room showed 4 framed pictures, one 70-inch Vizio television in its original box, two computer monitors, two CPU's and miscellaneous cords were stored against the wall adjacent to the Life Safety power breaker.
B. The above findings in "A" were verified by the Director of Maintenance at the time of observation.

Based on observation and interview, the facility failed to provide battery-powered emergency lighting for one of one emergency generator as required by NFPA (National Fire Protection Agency) 101, 2012 edition. The failed practice had the likelihood to affect all patients and staff in that in the event of a power outage emergency there would be no lighting to illuminate the work area around the generators, which would delay or prevent the maintenance required to keep the generators functioning. The findings were as follows:

A. Review of NFPA 101:9.1.3 2012 edition showed emergency generators must be installed and maintained in accordance with NFPA 110. Further review of NFPA 110:7.3.1 2010 edition showed emergency power equipment shall be provided with battery-powered emergency lighting.
B. Observation on 12/03/19 at 10:05 AM of the generator area showed the overhead lighting present was powered solely by the main electrical system, and no battery-powered lighting was present. This finding was verified by the Director of Maintenance at the time of observation.

Based on review of policy, Controlled Substance records and interview, it was determined the Pharmacist failed to follow acceptable standards of practice in that they failed to maintain biennial inventories of all controlled substances retained on file for one of one (June 2019) inventory due.. By not maintaining the biennial inventory, the facility could not assure complete and accurate records of their controlled substances were maintained. The failed practice had the potential to affect the control of controlled substances. Findings follow:

A. Review of policy titled, "Controlled Substance Biennial Inventory," showed that a biennial inventory of controlled substances was to be maintained.
B. Review of the Controlled Substance records showed the last biennial inventory was completed on 06/06/17.
C. During an interview on 12/2/19 at 1:30 PM, the Pharmacist verified the biennial inventory of controlled substances was not being maintained.

Based on observation, review of policy, review of CDC (Centers for Disease Control and Prevention) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Safe Injection Practices, review of APIC (Association for Professionals in Infection Control and Epidemiology) position paper and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying the practice of storing and reusing MDV (Multiple Dose Vials) once opened, in immediate patient treatment areas in one ( Anesthesia Cart #2) of two (Anesthesia Carts #1 and #2) observed. By not identifying the risk this practice carries, the facility could not assure patient safety. This failed practice has the likelihood to affect all patients receiving procedures in the facility. Findings follow:

A. Record review of the facility's policy titled, "Surgical Services Multiple Dose Vials, use of," effective date July 2016, showed all vials used in surgical services were single use only, unless specified by Pharmacy.
B. Review of review of CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, Safe Injection Practices showed facilities were not to keep multiple dose vials in immediate patient treatment areas (e.g. operating rooms and anesthesia carts).
C. Review of APIC position paper titled, "Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016)," showed MDV should never enter the immediate patient care area (e.g., operating room, anesthesia carts) and if they do, they must be dedicated for single patient use and discarded immediately after use.
D. During a tour of the facility on 12/02/19 from 2:15 PM to 3:30 PM, observation showed Anesthesia Cart #2 had the following:
1) One Labetalol 100 mg(milligrams)/20 ml(milliliters) MDV opened, dated 01/02/20, and stored on the Anesthesia Cart; and
2) One Lidocaine 1% 200mg/ 20ml MDV opened, dated 01/02/20, and stored on the Anesthesia cart.
E. During an interview on 12/2/19 at 2:50 PM, the Manager of the Operating Room, verified the findings in "D."


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Based on policy and procedure review, and observation, it was determined the facility failed to control infections in that one of one (#1) Patient Care Technician (PCT) did not clean the glucometer between patient uses. The failed practice did not prevent the spread of infection. The failed practice had the likelihood to affect all patients requiring glucose testing. Findings Follow:

A. Review of the policy and procedure titled, "Glucometer Blood Glucose Monitoring," effective September 2019, received on 12/02/19 at 2:00 PM showed after each patient use, clean the exterior surface of the Nova Stat Strip Glucose Meter with an approved disinfectant wipe.

B. During observation on 12/03/19 at 11:30 AM, showed PCT #1 performed blood glucose testing of Patient #21 at the bedside. After the testing was complete, PCT #1 returned the glucose meter to the Nurses' Station without cleaning the glucose meter. During interview on 12/03/19 at 11:40 AM PCT #1 stated that she was finished with the procedure.

C. Findings in "A and B" were verified by the Infection Control Officer at 11:45 AM on 12/03/19.


Based on observation and policy and procedure review, it was determined the Infection Control Officer failed to identify and control infections in that one of one (#1) Certified Registered Nurse Anesthetist (CRNA) did not clean the injection port prior to administering medications to one of one (#2) patient. The failed practice did not prevent the spread of infection. The failed practice had the likelihood to affect any patient who had a surgical procedure that required medication administered by CRNA #1

A. Review of the policy and procedure titled, "Central Venous Access Devices," effective April 2019, received at 12/03/19 at 10:00 AM showed scrub the needleless connector with alcohol for 15 seconds and let dry before accessing for all flushed and medication administration.
B. During observation on 12/03/19 at 12:45 PM, CRNA #1 failed to clean the injection port prior to administering intravenous (IV) medications to Patient #2.
C. During interview on 12/03/18 at 1:20 PM with Operating Room Manager, the above finding in "B" was verified.


Based on review of Association of Perioperative Registered Nurse (AORN) guidelines and interview, it was determined the Infection Control Officer failed to identify and control infections in that home laundered surgical scrub attire was worn in the operating room. Failure to ensure personnel wore scrubs that had been laundered at a health care accredited laundry facility did not assure patients would be protected from likely sources of infection. The failed practice was likely to affect all surgical patients.

A. Review of AORN guidelines for surgical attire showed all individuals who enter the semi-restricted and restricted areas should wear scrub attire that has been laundered at a healthcare-accredited laundry facility.
B. During interview with the Infection Control Officer on 12/02/19 at 2:30 PM, she stated that the facility followed the AORN and CDC guidelines. She also stated that all surgical personnel except the Certified Registered Nurse Anesthetists (CRNAs) and Physicians home laundry their scrubs.
C. During an interview with Manager of Operation Room on 12/02/19 at 1:30 PM, she stated that all scrubs were home laundered except for physicians and CRNA's.
D. During an interview with the Manager of Operating Room on 12/ 03/19 at 10:30 AM, she stated that the facility followed AORN guidelines for the Operation Room.
E. The above findings in "A" were verified with the Facility Administrator on 12/04/18 at 2:15 PM.
F. During interview on 12/03/18 at 1:20 PM with Operating Room Manager, the above findings in "B" were verified.

Based on interview with the Registered Dietitian Technician (RDT) and review of the Dietary Pattern Schedule, it was determined the facility failed to follow standards of practice in the organization of Dietetic Services in that there was no implementation of the Arkansas Rules and Regulations for Hospitals and Related Institutions in that food and nutrition services was not under the daily, including weekends for onsite supervision of a qualified dietary manager 7 (06, 12, 13, 19, 20, 26, and 27) of 31 (1-31) days in October and no CDM (Certified Dietary Manager) or RD (Registered Dietitian) scheduled in November 2019 for 8 (02, 03, 10, 16, 17. 23, 24 and 30) of 30 (1-30) days. The failed practice did not ensure patient assessments, counseling's, diet instructions, food preparation and storage were performed according to the facility policies. Findings follow:

A. Review of Arkansas Rules and Regulations for Hospitals and Related Institutions showed the Food and Nutrition Services were to be under daily supervision of a qualified individual. The individual at a minimum should be certified dietary manager.
B. During interview with the RDT on 12/03/19/19 at 1:15 PM she stated that she did not have 7 day a week coverage by a CDM or RD.
C. Review of the Dietary Pattern Schedule showed there was no CDM or RD scheduled in October 2019 for 7 (06, 12, 13, 19, 20, 26, and 27) of 31 (1-31) days and no CDM or RD scheduled in November 2019 for 8 (02, 03, 10, 16, 17. 23, 24 and 30) of 30 (1-30) days.
D. The above findings in A, B and C were verified with the RDT (Registered Dietetic Technician) on 12/03/19 at 1:15 PM.

Based on interview and clinical record review, it was determined the facility did not employ a qualified professional to direct the Swing-Bed Activities program. Failure to employ a qualified professional did not ensure the Swing-Bed patients receivied activities designed to meet their interests, physical, mental and psychosocial well-being. The failed practice affected Patients #22, #23, and all Swing- Bed admissions. Findings follow:

A. Interview with Director of Nurses on 12/04/19 at 1:30 PM she stated that the activities director had resigned and the facility has not been able to obtain an activities director.
B. Review of clinical records showed Patients #22 and #23 did not have a comprehensive activity assessment completed and no documentation of activities.
C. The above findings in "B" were verified by Director of Nurses on 12/04/19 at 1:30 PM.