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Based on review of January 2023 Crash / Stroke Cart Checklist Records (January 1 through January 8, 2023), review of policy and interview, it was determined the facility failed to ensure the contents of emergency supply carts were checked each shift (per policy) for five (Stroke 1, Stroke 2, Room 2, Pediatric and Trauma) of six (Stroke 1, Stroke 2, Room 2, Pediatric, Trauma and Medical/Surgical) carts observed. The potential existed for the emergency supply carts not to have medications/supplies/functional equipment present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications/supplies/functional equipment in an emergency. Findings follow:

A. Record review of facility policy titled "Crash Cart Policy," dated 05/10/2022, showed all Crash / Stroke Carts will be checked each shift and documented on the Crash / Stroke Carts Checklists.

B. During an interview on 01/10/23 at 1:00, the Director of Nursing verified the policy at A. The Director of Nursing also verified the policy covers all Emergency Carts (Stroke), not just Crash Carts.

C. During a tour of the facility on 01/09/23 from 1:15 PM to 2:32 the following carts had missing inspections documented on the January 2023 Crash / Stroke Carts Checklist Records (January 1 through January 8, 2023) :
1) Stroke Cart #1 was missing 4 AM shifts (01/03, 01/05, 01/07 and 01/08) and 2 PM shifts (01/04 and 01/05);
2) Stroke Cart #2 was missing 3 AM shifts (01/05, 01/07 and 01/08) and 2 PM shifts (01/04 and 01/05);
3) Room #2 Cart was missing 3 AM shifts (01/05, 01/07 and 01/08) and 3 PM shifts (01/05, 01/07 and 01/08);
4) Pediatric Cart was missing 4 AM shifts (01/04, 01/05, 01/07 and 01/08) and 2 PM shifts (01/04 and 01/05); and
5) Trauma Cart was missing 2 AM shifts (01/07, and 01/08) and 3 PM shifts (01/03, 01/04 and 01/05).

D. The missing inspections listed in C. were verified by the Director of Nursing at the time of observation on tour.

Based on above ceiling observation, review of National Fire Protection Association (NFPA) 101 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 and well-being of patients in that one of two fire barrier walls was not sealed in one location with fire-proof sealant 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 101, 12.9.6.2 showed 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 01/9/23 at 12:20 PM above ceiling observation in corridor adjacent to the nurses station showed one of two fire barrier walls with large penetrations measuring 10 inches by 10 inches inside of a 6 inches conduit with one penetrating black electrical wire. There was no evidence of a system or material capable of restricting the transfer of smoke.

C. The above findings were verified on 01/9/23 at 5:30 PM by the Maintenance Supervisor




Based on observation, review of National Fire Protection Association (NFPA) 101 Standards, it was determined the facility failed to ensure the building was maintained in that a tile was chipped on the floor and a hole was in the floor of the nurses's station medication room. And there was no sink provided in the nurses station medication room for staff to conduct hand hygiene. Failure to ensure the building was free of sharp edges, and holes in the floor had the likelihood for injury to all staff. Findings follow:

A. Observation on 01/9/23 at 4:17 PM showed there was a large hole in the floor measuring 10 inches by 15 inches in the nurses's station medication room in place of where the laboratory was.

B. Observation of the nurses's station medication room on 01/9/23 at 4:22 PM showed that there was no sink provided in the nurses's station medication room for staff.

C. The findings were verified by the Maintenance Supervisor on 1/9/23 at 6:15 PM

Based on observation of the Respiratory Therapy Suite it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practices promoted the spread of infection and had he likelihood to affect all patients, staff and visitors, Finding follow:

A. Observation of patient shower room located on the main hallway on 01/09/23 at 2:18 PM showed mold present in the patient shower and debris around toilet and residue on mirror and around sink handles.

B. Observation of the Respiratory Therapy Suite on 1/09/23 at 4:45 PM showed broken and stained ceiling and floor tiles.

C. Observation of the Respiratory Therapy Suite on 1/9/23 at 5:05 PM showed multiple wires hanging from the ceiling.

D. Observation of the Respiratory Therapy Suit on 1/9/23 at 5:20 PM showed that the area was being used as a patient equipment storage area with cleaning supplies, and also used as the nurses lounge with no barrier separating the spaces.

E. The above findings were verified by the Maintenance Supervisor on 1/9/23 at 6:20 PM

Based on observation and interview the facility failed to provide battery-powered emergency lighting 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 in procedure rooms and had the likelihood to affect all patients undergoing procedures. Findings follow:

A. Review of NFPA 99-2012, refered to by NFPA 101 section 6.3.2.2.11.1 requires one or more battery-powered lighting units within locations where deep sedation and general anesthesia administered.

B. Observation on 01/09/23 at 1:15 PM showed that there were no battery powered emergency lights provided in 2 of 2 procedure rooms.

C. The findings in A and B were verified by the maintenance supervisor on 01/09/23 at 6:15 PM

Based on review of policy, manufacturer's storage recommendations, observation, review of IV (Intravenous) Fluid Temperature Log and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for storage of IV (Intravenous) solutions in one of one fluid warmer. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the solutions available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required IV fluids. Findings follow:

A. Record review of facility policy titled, "Medication Storage Policy," dated 01/28/2019, showed medications would be stored according to manufacturer's recommendations.

B. Review of manufacturer's storage recommendations for Baxter Lactated Ringers IV solutions showed they should be stored at room temperature. The product could be briefly exposed up to 40 degrees Celsius (104 degrees Fahrenheit) but does not mention storing at higher temperatures.

C. During an interview on 01/11/23 at 10:30 AM, the Director of Pharmacy verified the Manufacturer's storage recommendations for Baxter Lactated Ringers IV solutions showed they should be stored at room temperature.

D. During a tour of the facility on 01/09/23 from 1:15 PM to 2:32 PM, observation showed five
1000 milliliter Baxter Lactated Ringers IV solutions stored in a fluid warmer with a recorded temperature of 100 degrees Fahrenheit on the IV Fluid Temperature Log.

E. The Director of Nursing verified the five 1000 milliliter Baxter Lactated Ringers IV solutions stored in a fluid warmer with a registered temperature of 100 degrees Fahrenheit, at the time of observation.

Based on policy and procedure review, Weekly Tray Temperature Form review for 10/01/22 through 12/31/22 and interview, it was determined the facility failed to follow its policy on serving food temperatures at the minimum of 135 degrees Fahrenheit. The failed practice did not allow the kitchen staff to know if hot foods were above 135 degrees Fahrenheit through the duration of the meal service. The failed practice had the likelihood to affect anyone receiving food from the kitchen. Findings follow.

A. Review of the facility's policy and procedure resourced from the Arkansas Department of Health, Food Preparation Temperature requirements showed that all pre-cooked food should be heated to 165 degrees Fahrenheit and served at a minimum of 135 degrees Fahrenheit.

B. Review of Weekly Tray Temperature Form for 10/01/22 through 12/31/22 showed the following:
1) The recommended serving temperatures for hot entrée was 140-165 degrees Fahrenheit.
2) The recommended serving temperatures for cooked vegetables was 140-165 degrees Fahrenheit.
3) There was no evidence of documentation as to how long plating (hot food onto room temperature plates) lasted at each meal. Therefore, it was unknown as to whether or not food temperatures should be taken at the end of service line.
4) There was no evidence of temperature documentation before the patient meal tray through the last patient meal tray.

C. During observation on 01/11/23 11:00 AM through 12:30 PM, of plating and patient mealtime service the following was observed:
1) Each patient tray was plated individually with a beginning temperature for hot entrée of 155 degrees Fahrenheit and vegetables of 120 degrees Fahrenheit.
2) After the plating, each plate was covered with aluminum foil.
3) After each tray was placed on the service rack, the trays were covered with a vinyl drape.
4) At 12:10 PM, prior to the first tray being served, the entrée temperature was 129 degrees Fahrenheit, and the vegetables were 105 degrees Fahrenheit.
5) At 12:25 PM, prior to the last tray being served, the entrée temperature was 110 degrees Fahrenheit, and the vegetables were 101 degrees Fahrenheit.

D. During an interview on 01/11/23 at 12:25 PM, the Dietary Manager confirmed the findings in A-C.

Based on observation, review of manufacturer's guideline and interview, it was determined that two of two opened bottles of StatStrip Glucose Control Testing Strips were not dated as to when opened to assure they had not expired. The failed practice had the likelihood to affect the laboratory results and had the likelihood to affect any patient when a blood glucose was drawn. Findings showed:

A. Review of manufacturer's guideline, " StatStrip Glucose Hospital Meter System," showed that once the test strips are opened, they are stable for six months or until the expiration date, whichever comes first.

B. Observation of 01/09/23 at 1:30 PM of the StatStrip Glucose Testing Strips showed there was no date of opening to determine the
expiration date.

C. During observation on 01/09/23 at 1:30 PM, the Director of Nursing confirmed the findings in A-B.

Based on review of Physical Therapy Assistant's Job Description, review of Physical Therapy Assistant's (PTA) personnel file and interview, it was determined one (PTA #7) of seven (PTA #1-#7) did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per Physical Therapy Assistant's Job Description. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Record review of Physical Therapy Assistant's Job Description showed that one of the minimum qualifications is to be CPR certified.

B. Review of PTA #7's personnel file showed PTA #7's CPR certification expired 11/30/22.

D. During an interview on 01/12/23 at 9:38 AM, the Director of Quality verified PTA #7's CPR certification expired 11/30/22.

Based on observation, review of manufacturer's guideline and interview, it was determined that two of two opened bottles of Digital Instant Read Thermometer Probe were not cleaned after use to assure prevention of food born illness. The failed practice had the likelihood to spread a food born illness had the likelihood to affect any patient food being served. Findings showed:

A. Review of manufacturer's guideline, " Digital Instant Read Thermometer," showed that the probe was to be cleaned with a damp cloth before and after use.
B. Observation of 01/11/23 at 11:30 AM showed Dietary Manager #2 was testing the patient tray ( not a test tray) temperature using the Digital Instant Read Thermometer Probe and showed cleaning the probe after use with an alcohol wipe.
C. During observation on 01/11/23 at 11:30 AM, the Dietary Manager #2 confirmed the findings in A-B.



46069

Based on observation, review of product label, and interview, it was determined the facility failed to maintain a sanitary environment in the Trauma Room of the Emergency Department (ED) by not removing and replacing expired supplies for patient use. Failure to ensure available patient care supplies were within the recommended date for use did not assure the supplies were safe for patient use. The failed practice had the potential to affect all patients receiving care in the Trauma Room of the ED. Findings follow.

A. During a tour of the Trauma Room in the ED on 01/09/23 at 12:40 PM, the following supply labels were reviewed and determined to be expired.
1. Teleflex Laryngeal Mask Airway, size five, quantity of one, expired 11/28/2021.
2. Bardex Foley Catheter, Size 16 French, quantity of one, expired 02/28/22.
3. Medline Elastoner Coated Latex Foley Catheter, Size 6 French, quantity of four, expired 10/28/2022

B. The findings in A were verified in an interview with the Director of Nursing on 01/09/23 at 12:52 PM.

Based on clinical record review and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the POC for four of four (#19-#22) swing bed patients. The failed practice had the likelihood to effect continuity of care. The failed practice had the likelihood to affect all patients admitted to the Swing Bed Unit. The findings follow:

A. During an interview on 01/12/23 at 10:30 AM, Director of Nursing (DON) confirmed there was no evidence of policies for IDT to complete a POC.

B. Review of clinical record of Patient #19 on 01/12/23, admitted 12/20/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 01/12/23 at 10:45 AM, Nurse Supervisor (NS) confirmed the findings in B 1-3.

C. Review of clinical record of Patient #20 on 01/12/23, admitted 01/03/23, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 01/12/23 at 11:00 AM, NS confirmed the findings in C 1-3.

D. Review of clinical record of Patient #21 on 01/12/23, admitted 11/04/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 01/12/23at 11:15 AM, NS confirmed the findings in D 1-3.

E. Review of clinical record of Patient #22 on 01/12/23, admitted 12/15/22, showed the following:
1) No evidence the IDT formulated the patient's plan of care.
2) No evidence the IDT completed the weekly assessment in the patient's plan of care.
3) On 01/12/23at 11:30 AM, NS confirmed the findings in E 1-3.

Based on review of the facility's policy and procedures plan and interview, it was determined the facility failed to follow the Emergency Preparedness plan in that the plan was not reviewed on an annual basis. The failed practice had the likelihood to affect all patients and staff in the event of an emergency. Findings follow

A. Review of the facility's policy and procedures on 01/09/23 at 12:45 PM showed the facility was to maintain an annual Infrared breaker check.

B. Review of the facility's policy and procedures on 01/09/23 at 12:55 PM showed that the facility was to maintain and update annual Polarity and intention test

C. Review of the facility's policy and procedures plan on 01/09/23 at 1:00 PM showed The facility was to perform a lgionella water test on an annual basis.

D. In an interview with the Maintenance Supervisor on 1/9/23 at 6:20 PM, he confirmed the facility failed to maintain an annual infrared breaker check, maintain and update the annual polarity and intention test, and perform a legionella test on an annual basis.



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