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I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to have a system in place to monitor the water temperature in 1 of 1 hydrocollator located in the inpatient care area to ensure the temperatures were in an acceptable range in accordance with the facility policy. The facility was unable to identify how many times the CAH staff used a hot pack from the hydrocollator located in the inpatient care area. The facility census was 4 patients on entrance on 2/14/19.

A Hydrocollator is a stainless-steel thermostatically controlled liquid heating device designed to heat silicone packs in water. The packs were then removed and wrapped in several layers of toweling and applied to a patient's affected area to relieve acute pain.

Failure to monitor water temperature in the hydrocollator could potentially cause serious burns to patients during hot pack therapy.

Findings include:

1. Observation on 2/14/19 at 1:30 PM, during a tour of the Physical/Occupational Therapy room located in the CAH, with the Director of Nursing (DON) and Physical Therapy Assistant (PTA) B, revealed 1 of 1 Hydrocollator unit (a liquid heating device used in physical therapy to heat and store hot packs for therapeutic use of moist hot packs on patients) that contained approximately 2 small and 4 large hot packs immersed in hot water.

2. Review of Physical Therapy policy/procedure, "Moist Hot Packs, dated 10/2018, revealed in part, "...The water should be hot, 150 [degrees] to 170 [degrees] F [Farenheit], as per digital read-out on unit, standard for our unit is 160 [degrees]...."

3. Review of document, "Temperature Control Checklist" for December 2018, revealed the water temperature in the hydrocollator located on the inpatient unit was last checked on 12/12/18.

The Physical Therapy department staff failed to monitor the hydrocollator water temperature daily per interview with PTA B.

4. During an interview on 2/14/19 at 1:30 PM, PTA B, stated the Physical Therapy staff checked the hydrocollator water temperature daily when the hot packs were used. PTA B demonstrated how the staff checked the hydrocollator water temperature and picked up a thermometer from the counter. The thermometer registered 120 F degrees when PTA B picked up the thermometer from the counter. PTA B then checked the hydrocollator water temperature and the thermometer registered 180 degrees F. PTA B stated the thermometer was off by 10 degrees and the water temperature was 170 degrees. PTA B then obtained another thermometer and the hot water temperature was 170 degrees.

During an interview on 2/18/19 at 11:25 AM, Physical Therapist (PT) F, acknowledged the "Moist Hot Pack" policy/procedure failed to address how often the hydrocollator temperature was to be checked but stated the temperature was checked daily 5 days/week and not on the weekend. PT F stated the hydrocollator temperature should be checked daily and also need to use an appropriate thermometer.


II. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to clean the hydrocollator located in the inpatient unit weekly in accordance with the facility policy. The facility was unable to identify how many times the CAH staff used a hot pack from the hydrocollator located in the inpatient care area. The facility census was 4 patients on entrance on 2/14/19.

A Hydrocollator is a stainless-steel thermostatically controlled liquid heating device designed to heat silicone packs in water. The packs were then removed and wrapped in several layers of toweling and applied to a patient's affected area to relieve acute pain.

Failure to clean patient care equipment could result in the spread of bacteria, infections, and communicable diseases between patients.

Findings include:

1. Observation on 2/14/19 at 1:30 PM, during a tour of the Physical/Occupational Therapy room located in the CAH, with the Director of Nursing (DON) and Physical Therapy Assistant (PTA) B, revealed 1 of 1 Hydrocollator unit (a liquid heating device used in physical therapy to heat and store hot packs for therapeutic use of moist hot packs on patients) that contained approximately 2 small and 4 large hot packs immersed in hot water.

2. Review of Physical Therapy policy/procedure, "Moist Hot Packs, dated 10/2018, revealed in part, "...The large unit should be cleaned once a week, preferably on weekends when less patient volume...."

3. Review of document, "Equipment Cleaning List" for 2017, 2018, and 2019 revealed the hydrocollator was cleaned monthly and was last cleaned December 2017.

The Physical Therapy department staff failed to clean the hydrocollator weekly as stated in the policy.

4. During an interview on 2/18/19 at 11:25 AM, Physical Therapist (PT) F, stated the hydrocollator was not cleaned weekly as stated in the policy/procedure but should be cleaned monthly.

PT F acknowledged the hydrocollator was not cleaned weekly in accordance with the policy/procedure.

During an interview on 2/18/19 at 11:50 AM, PTA B acknowledged the hydrocollator in the inpatient unit was not documented as cleaned weekly and the last time it was documented the hydrocollator was cleaned was December 2017.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH's) administrative staff failed to:

1. Ensure nursing staff were trained on the use of moist hot packs and adequately monitored a patient with a moist hot pack which resulted in a burn. Please refer to C-0294.

2. Ensure the hot water temperature in 1 of 1 hydrocollator located on the inpatient unit was maintained at a safe and acceptable temperature. Please refer to C-0222.

The cumulative effect of these failures and deficient practices resulted in the CAH's inability to provide safe patient care. The facility census was 4 patients on entrance on 2/14/19.


II. During the investigation of complaint #81361-C, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that place the health and safety of patients at risk) related to the Condition of Participation for Provision of Services (42 CFR 485.365). The hospital staff failed to ensure staff were trained on the use of moist hot packs and adequately monitored a patient with a moist hot pack which resulted in a burn.

1. The CAH administrative staff failed to initially develop and implement a corrective action plan to ensure the nursing staff were trained on the use of moist hot packs and adequately monitored a patient with a moist hot pack.

2. While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 2/19/19. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the administrative staff took the following actions:

a. The CAH's administrative staff sent an email to all nursing staff by the Director of Nursing (DON) the staff to no longer use the hot moist packs, that if an order was needed for moist heat, to obtain an order for an aqua K pad from the provider. (An aqua K pad was a plastic pad that could be applied for sprain, edema, or inflammation. The pad contains channels through which heated water flows.)

b. Nursing staff were instructed in the email sent to all nursing staff by the DON to read the aqua K pad procedure prior to application. All nursing staff were instructed to sign and date the email, verifying that they have read and understand the email communication.

c. The Hydrocollator unit that contained the moist hot packs was removed from the inpatient unit on 2/18/19 and placed in the Physical Therapy department in a building adjacent to the CAH and not connected directly to the CAH. The nursing staff did not have access to the Physical Therapy department building.

Based on observation, review of documents and patient medical records, and staff interviews, the Critical Access Hospital (CAH) failed to ensure nursing staff were trained on the use of moist hot packs and adequately monitor 1 of 1 patient with a moist hot pack which resulted in a burn (Patient #1). The facility census was 4 patients on entrance on 2/14/19.

Failure to ensure the nursing staff were trained on the use of moist hot packs and adequately monitor patients with a moist hot pack resulted in the patient having received a burn.

Findings include:

1. Observation on 2/14/19 at 1:30 PM, during a tour of the Physical/Occupational Therapy room located in the inpatient unit, with the Director of Nursing (DON) and Physical Therapy Assistant (PTA) B, revealed 1 of 1 Hydrocollator unit (a liquid heating device used in physical therapy to heat and store hot packs for therapeutic use of moist hot packs on patients) that contained approximately 2 small and 4 large hot packs immersed in hot water.

2. Review of Nursing policies/procedures revealed the lack of a policy on the use of moist hot packs.

Review of Physical Therapy policy/procedure, "Moist Hot Packs, dated 10/2018, revealed in part, "...Starting the treatment:...Explain the procedure to the patient
a. The heat from the packs should be comfortable warm and not hot.
b. It may take several minutes for the patient to feel the warmth.
c. If the packs are too hot or too heavy or if any other discomfort develops, the patient should call you IMMEDIATELY...Use CAUTION: The packs are hot and heavy and the patient can be burned if applied improperly and patient not monitored...Application procedure:...Inspect skin before and after treatment...Check the patient after a few minutes...The treatment time is usually fifteen to thirty minutes...CONTRAINDICATIONS/PRECAUTIONS...Burns can occur; pad hot packs more for older patients and those that lay on the pack...."

3. Review of Patient #1's medical record revealed the following in part:

a. History and Physical dated 1/17/19 by Advanced Registered Nurse Practitioner (ARNP) H revealed Patient #1 admitted 1/17/19 for blurred vision at times, nausea with taking medications, and generalized weakness. Had been seen 2 times in the Emergency Room within the past 3 days with complaints of loose bowels, feeling weak, and having difficulty urinating and was placed on antibiotics for possible infection. Diagnoses at the time of admission was hyponatremia (low sodium in the blood), hypertension, and anxiety. Admit for IV fluids and monitoring.

b. Nursing Assessment note by Registered Nurse (RN) G - 1/18/19 at 11:14 PM; 1/19/19 12:14 AM; and 1/19/19 at 1:05 AM - Patient resting with eyes closed sitting in recliner.

c. Nursing Assessment note by RN G - 1/19/19 at 2:07 AM - Patient up in recliner, assisted to bathroom. Upon return to bed patient complains of sore spot low back, area of skin breakdown noted, no drainage.

d. ARNP note 1/19/19 at 1:06 PM in part - Patient had complaint of back pain last evening. He was given a hot pack from PT that was wrapped in a towel. Patient reports that the pack was hot, but he liked the warmth as he was cold in his room. This morning, the nurse noted a red area across his lumbar area and a large serous filled blister to the left lumbar region. Lumbar region of the back - open area noted to the left 4 by 8 cm, red wound bed, serous drainage from the wound. Second area noted to the right lumbar region 2.5 cm in diameter, serous filled, no drainage. Periwound (tissue surrounding the wound) skin is erythemic (reddened) across the lumbar region from left to right.

The patient's medical record lacked documentation by nursing staff that a hot pack was placed on the patient and lacked any monitoring of the patient's skin after the hot pack was applied, until 4 to 5 hours later, when the patient requested to go to the bathroom.

4. During an interview on 2/18/19 at 1:05 PM, RN A stated they placed a moist hot pack to Patient #1's back on 1/18/19 at bedtime when the patient was sitting in a recliner as the patient stated they were cold. RN A acknowledged they had not received any education on the use of the moist hot pack prior to having used it on Patient #1 on 1/18/19. RN A verified the moist hot pack was left on the patient at least 2 or more hours and did not check on the patient during that time. RN A stated when the patient had put on their call light and was assisted to the bathroom on 1/19/19 at 1:30 AM, the nursing staff noticed a broken blister to the patient's mid back. RN A stated the patient did not complain of any pain or discomfort.

During an interview on 2/14/19 at 2:00 PM, the Assistant Director of Nursing (ADON) stated when they talked to the patient, the patient stated they adapted to the situation and then fell asleep on the hot pack. The ADON stated there had not been any education provided to the nursing staff regarding the use of the use of moist hot packs. The ADON acknowledged the physical therapy policy/procedure regarding the use of moist hot packs had not been shared with the nursing staff.

During interview on 2/18/19 at 9:55 AM, RN C acknowledged they started work at the CAH several years ago, their supervisor showed them how to put on a moist hot pack. RN C verified they had not received any education on the use of moist hot packs in 2019.

During an interview on 2/18/19 at 10:30, Licensed Practical Nurse (LPN) D acknowledged they had not received any education on the use of moist hot packs in 2019. LPN D stated they can not remember any education on the use of moist hot packs since therapy showed them many years ago.

During an interview on 2/18/19 at 10:45 AM, RN E stated when they had not received any education on the use of moist hot packs since physical therapy did first education many years ago.

During an interview on 2/18/19 at 11:25 AM, Physical Therapist F revealed the therapy department had never provided an inservice to the nursing staff on the use of the moist hot packs.