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I. Based on observations, document review and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to ensure patient safety from burns related to hot water temperatures. Problems identified with hot water temperatures in patient care areas on the acute, obstetrical, and physician clinic areas. The CAH identified an average daily census of 6 inpatients, an average yearly census of 45 obstetrical deliveries, and an average daily census of 20 off-site clinic patients.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 1 second at 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees.

Findings include:

1. Observations during a tour of the acute care floor, accompanied by the Chief Executive Officer (CEO) and the Support Services Manager on 9/20/10, revealed the following hot water temperatures confirmed by the Support Services Manager using their thermometer.

a. Room #401: 131.2 degrees at 10:45 AM.
b. Room #408: 130.8 degrees at 10:55 AM.

2. Observations during a tour of the obstetrical floor, accompanied by the CEO and the Support Services Manager on 9/20/10, revealed the following hot water temperatures confirmed by Support Services Manager using their thermometer:

a. Nursery: 131.5 degrees at 11:00 AM.
b. Room #414: 130.6 degrees at 11:00 AM.
c. Room #415 (baby bath sink): 125 degrees at 11:15 AM.

3. During an interview on 9/20/10 at 10:45 AM, Staff L, Maintenance Services Manager, verified the elevated hot water temperatures in the acute care and obstretical areas. Staff L stated, "We had the mixing valve worked on this morning and the company was called back."

4. Observation during a tour of Practitioner A's clinic on 9/21/10 revealed the following hot water temperatures:
Exam room #3: 139.8 degrees at 1:00 PM. Staff K, Licensed Practical Nurse (LPN) confirmed findings and contacted the maintenance department.

a. Staff M, Construction Supervisor, arrived to exam room #3 at 1:10 PM. Staff L stated, "Right now the temperature is 136 degrees. Temps for water should run between 110-120 degrees. I will check into this and make adjustments."

b. Survey staff, accompanied by Staff N, obtained a follow-up water temperature of 124.7 degrees in exam room #3 of the physician clinic on 9/22/10.

c. At the time of the follow-up monitoring, Staff N, said, they started started monitoring and recording water temperature in patient rooms every two hours this morning (9/22/10). Staff N reported obtaining a temperature of 125.7 degrees in exam room #3. Staff N did not know why the temperature was so hot. According to Staff N, the boiler reading was 119 degrees and h/she had made adjustments approximately 45 minutes earlier. Staff N stated they would follow up for the next two days every two hours. Staff N thought the actual dial on the tank itself was bad. Staff N reported the boiler was registering 130 degrees this morning. The mechanical engineering group came in to trouble shoot temperatures on Monday and they put a call in to them for this problem as well.

5. During an interview on 9/21/10 at 1:30 PM, Staff M reported the maintenance staff did not monitor water temperatures in patient care areas, bathrooms or clinic offices. Staff M further reported that, all of the temperature readings came from the gauges on the hot water heater.

6. Review of A document titled "Plan of Corrective Action High Hot Water Temp Davis County Hospital" provided to the surveyor by Staff N, on 9/22/10 at 2:15 PM revealed the following information.

"As of 1:55 PM on 9/22/10 have contacted [a boiler mechanical group] in DesMoines [sic] and trouble shot over the phone, coming to the conclusion that the steam valve itself is faulty. They are currently figuring out whether it would be easier to rebuild the valve or to just replace it. It currently looks as though Friday September 23, 2010 would be the soonest that parts or replacement would be able to be onsite. In order to remedy problem.

During this time frame we have and will continue to monitor at the outlets every two hours during operation times to ensure that temp doesn't rise above acceptable levels, as we have been. We have also set the HIGH LIMIT SWITCH (emergency dump) at 125 degrees. If water temps in the tank should reach 125 then the tank automatically empties and fresh water (70 degrees) is then used to refill the system. This will ensure that no one could possibly be injured. During operation hours until fixed, we will continue to monitor temps at the outlets to ensure safety."


II. Based on observations, document review and staff interview the CAH obstetrical staff failed to remove expired infant formulas from the nursery. The CAH identified an average yearly census of 45 obstetrical deliveries.

Failure to remove expired baby formula from the formula available for patient use could result in babies receiving formula that the manufacturer could no longer assure was safe.

Findings include:

1. Review of the Expiration of Obstetrical Supplies Procedures manual, approved 9/29/10 revealed in part; "Patient care supplies in the obstetrics department will be checked monthly to monitor expiration dates...Those items found expired will be disposed of and new stock will be obtained."

2. Observations, during a tour of the nursery workroom in the obstetrical area, on 9/20/10 at 12:20 PM, accompanied by the Acute Care Manager revealed the following expired infant formula available for patient use.
a. Two of 2 - 12.8 ounces (oz) cans of Similac Neo-Sure Infant Powder formula with iron labeled with an expiration date of 8/1/10.
b. Twenty seven of 27 - 2 oz. bottles of Similac Sensitive Infant formula with iron labeled with an expiration date 9/1/10.

3. During an interview on 9/20/10 at 4:05 PM, Staff O, Registered Nurse (RN) reported nursing staff are responsible for checking supplies monthly. He/she stated, "The sheet with the last formula checks were done in September by [nurse P]." Staff O disposed of the expired infant formula at the time of the interview.

Based on observation, staff interview, and dietary policy/procedure review,
the dietary staff, failed to maintain a clean and sanitary area. The areas of concern included: carbon build-up on the inside of 20 of 20 sheet pans; moderate amounts of dirt and debris on 3 of 3 floor fans and 2 of 2 walk-in cooler fans; a moderate amount of carbon build-up on the back splash of the range; a moderate amount of dirt and debris on the fire extinguisher system in the range hood; and a moderate amount of dried on debris and food crumbs on the interior bottom of the True silver refrigerator. The CAH dietary staff produced about 150-380 meals per day.

Failure to maintain a clean and sanitary environment in the areas where food preparation occurs could potentially place the hospital ' s patients, staff, and visitors at risk for harm from ingesting unsafe food and fire hazards.

Findings include:

1. During the initial dietary tour with Staff B, the Dietary Manager on 9/13/10 at 2:00 p.m., observation revealed the following concerns. There was a moderate amount of dirt and debris on the fan blades and front surfaces of 3 of 3 Air King floor fans, on 2 of 2 fans in the walk-in cooler, and on the fire extinguisher system of the range hood. The fire extinguisher system of the range hood is a black pipe system that runs from the sides of the hood to the front. Accumulated on the outside of the black piping was a moderate amount of dirt and debris, with some of the dirt and debris hanging off the piping. There was carbon build up on the back splash of the Imperial range. There was carbon build up on the inside of 20 of 20 sheet pans. Carbon build-up is a residue that forms on pans surfaces when cleaning procedures fail to remove grease and other food debris after each use. The carbon build up can leach into foods during cooking and affect the taste and potentially contaminate the food. There was an accumulation of dried on debris and food crumbs on the bottom of the True silver refrigerator

2. During an interview on 9/20/10 at 2:42 p.m., Dietary Manager confirmed the dietary staff failed to remove carbon build-up from the sheet pans and the back splash of the range. The dietary staff failed to remove the dirt and debris accumulation from the fans. The dietary staff failed to maintain a clean silver refrigerator. The Dietary Manager identified the maintenance staff as responsible for maintenance and cleaning of the floor fans, cooler fans, and range hood area.

3. Review of the dietary department ' s policy/procedure manual, on 09/21/10, revealed a policy titled, " Standard Operating Procedures, Pots and pans Washing Procedures " with a review date of 6/10. The policy stated in part ... " Cleaning the Cooking Equipment in a Food Service Department is a very important job. To be free from bacteria that could produce food-borne illness, these utensils have to be thoroughly washed, rinsed, and sanitized. The Davis County Hospital Dietary Department will keep all pots and pans thoroughly washed, rinsed, and sanitized ... "

The dietary department ' s policy/procedure manual lacked a policy that delineated cleaning of carbon build-up from the back splash of the range, removing the dirt and debris build-up from the floor fans and cooler fans or cleaning of the refrigerator.

4. Review of the monthly " Storeroom Tech Cleaning Weekly " document, for September 2010, revealed the cleaning record for the floor fans and stove hood were on the list. The dietary staff failed to document the completion of the weekly cleaning list for the floor fans, cooler fans, and stove hood by maintenance during the month.

Review of the " Daily Cleaning Chart " document for September 2010, revealed the list included daily cleaning of the top of the stove. The dietary staff failed to document completion of the daily cleaning chart on 3 of 21 days of September.

The CAH dietary staff failed to develop and implement cleaning schedules delineating the removal of carbon build-up from the back splash of the range and inside of sheet pans or the removal of dirt and debris build-up from the range hood, cooler fans, floor fans, and the silver refrigerator.

Based on policy/procedure review, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to include all practitioners that provided care and services to the CAH patients, in their external peer review process. Problems identified with 1 of 1 physician/Pathologist that provided services to patients of the CAH. (Practitioner B)

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

Review of CAH policy/procedure titled "Peer Review" approved on 1/18/10 revealed the following in part, "PURPOSE: To evaluate the quality and appropriateness of diagnosis and treatment outcomes. PROCEDURE: On a biennial basis one record from each medical provider shall be submitted for external review."

The external peer review documentation for the past credentialing period of 2 years showed that Pathologist B was not included in the CAHs external peer review process.

During an interview on 9/22/10 at 9:00 AM, the Director of Organizational Excellence stated Practitioner B did not have an external Peer review completed since the last credentialing period that ended on 5/17/10. The Director Organizational Excellence stated Practitioner B had provided services to patients of the CAH during the last credentialing period.