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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Cardiac Rehabilitation nurse tested 1 of 1 Lifepak 12 Defibrillator in the Emergency Room according to manufacturer's recommendations. The Director of Nursing identified an average of 50 Emergency Room visits per month.

Failure to test the defibrillator according to the manufacturer's recommendations could potentially result in the defibrillator failing to shock a patient when needed.

Findings include:

1. Observations during a tour of the Emergency Room on 12/21/10 at 7:30 AM revealed 1 of 1 Physio-Control Lifepak 12 defibrillator.

2. Review of the "[Emergency Room] Defibrillator Log" next to the Emergency Room defibrillator revealed CAH staff only tested the defibrillator once per week.

3. During an interview at the time of the tour, the Director of Nursing stated the policy stated the Cardiac Rehabilitation nurse checked the defibrillator once per week.

4. Review of the policy "Defibrillator Checks", effective 2/00, revealed in part, "The [Emergency Room] defibrillator will be checked by the Cardiac Rehabilitation Nurse on a weekly basis.... The date, time, and individual checking will be recorded on a log sheet kept by the defibrillator."

5. Review of the Physio-Control Lifepak 12 Operating Instructions, copywrite 2/01, revealed in part, "Recommended Maintenance Schedule for Clinical Personnel... User Test ... Daily"

6. During an interview on 12/21/10 at 1:21 PM, the Cardiac Rehabilitation nurse reported working as the Cardiac Rehabilitation nurse for 3 years. The prior Cardiac Rehabilitation nurse taught him/her to test the defibrillator once per week, in accordance with the CAH policy. The Cardiac Rehabilitation nurse further stated s/he would begin testing the defibrillator every day.

7. Review of an e-mail sent from a Physio-Control Technical Support Specialist, dated 12/22/10 at 11:16 AM, revealed in part, "...we provide basic guidelines on what should be tested and at what intervals ... we leave the final decision up to the medical director at each facility to interpret what is important to their facility."

8. Review of a purchase order, dated 7/25/01, revealed the CAH administrative staff purchased the Lifepak 12 defibrillator used in the Emergency Room on that date.

9. Review of the Medical Staff meeting minutes for 8/14/01 revealed the medical staff received an in-service on the operation of the Lifepak 12 defibrillator. The Medical Staff meeting minutes lacked documented evidence of the medical staff, or medical director, considered and approved testing the defibrillator on a weekly schedule, despite the manufacturer recommended testing the Lifepak 12 daily.

10. Review of the CAH Professional/Advisory Committee meeting minutes (the committee responsible for approving changes to CAH policies and procedures), dated 6/17/02, revealed the Quality Assurance/Utilization Review nurse updated Emergency Room policies to reflect the new defibrillator. The meeting minutes lacked documented evidence of the committee, or medical director, considered and approved testing the defibrillator on a weekly schedule, despite the manufacturer recommended testing the Lifepak 12 daily.

11. During an interview on 12/22/10 at 3:30 PM, the Quality Assurance/Utilization Review nurse stated they could not remember if they presented the manufacturer's recommendations for testing the Lifepak 12 to the CAH Professional/Advisory Committee, or if the committee discussed changing the frequency of testing the Lifepak 12 from the manufacturer's recommendations.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the radiology staff tested 1 of 1 Cidexplus Solutions in the ultrasound room. The Radiology Director stated radiology staff performed an average of 1 internal probe procedure per week.

Failure to test the disinfecting solutions prior to each use could potentially result in staff using disinfecting solution that lacked sufficient strength of the active ingredient to kill all microorganisms, resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations, during a tour of the Radiology department, on 12/20/10 at 3:20 PM revealed 1- Cylindrical Soak Container of Cidexplus Solution, mounted on a wall in the ultrasound room. The Radiology Director stated, "We do not test the Cidexplus solution. We do not have the test strips here that I know of. I'm going to ask the ultrasound sonographer if he/she's doing it. The sonographer changes the solution and replaces it with a new batch. He/she maintains the log." [the log demonstrating when the solution was changed].

2. During a follow up interview on 12/20/10 at 3:25 PM, the Radiology Director reported
he/she spoke with the ultrasound tech and the tech acknowledged that he/she did not check the Cidexplus solution prior to each use. The Radiology Director stated, "We're not going to do anymore [internal] probe procedures until we get the test strips."

3. During an interview on 12/ 21/10 at 7:20 am, the Assistant Administrator confirmed that radiology staff had failed to test the Cidexplus solution prior to use in accordance with CAH policy and the manufactures recommendations.

4. Review of the policy, "Chemical Disinfectants", reviewed July 2010, revealed in part, "... items which contact mucus membranes ... must receive at least high level disinfection. When ... glutaraldehyde (Cidex or Cidexplus) ... is used, it must be in accordance with the following instructions.... Follow manufacturer's instructions"

5. Review of the manufacturer's directions for Cidexplus, revised 2003, revealed in part, "Test the solution prior to use to ensure the glutaraldehyde concentration is above the minimum effective concentration. Cidexplus Solution Test Strips must be used for this


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II. Based on review of documents, observation and staff interviews the Critical Access Hospital (CAH) Dietary Manager failed to follow Special Contact Precautions Isolation for 1 of 1 acute patients (Patient #1) admitted with Special Contact Precaution Isolation. The CAH administrative staff reported a census of 1 acute and 2 skilled in-patients.

Failure to follow Special Contact Precaution Isolation procedures could potentially result in the spread of infection to other patient and/or staff.

Findings include:

1. Observation on 12/21/10 at 11:53 revealed:

a. Staff A, Dietary Manager, removed Patient #1's meal tray from the insulated delivery cart. Staff A carried the meal tray into Patient #1's room. Staff A placed the meal tray on the over the bed table. Additional observation showed a sign posted on Patient #1's door that read, "Special Contact Precaution." sign stated in part, "...wear gloves when entering this room, hand hygiene when gloves are removed and before/after all patient care, wear gown when entering this room..." This alerted visitors and staff of the special precautions to follow prior to entering the patient's room.

b. Staff A removed used tissue and papers off the over the bed table, disposed of items in the wastebasket in room. After touching contaminated items, Staff A removed the covers from the meal plate and coffee cup. Staff A contaminated his/her clothing while assisting Patient #1. Staff A cleansed hands with alcohol gel, left the room and proceeded to the insulated delivery cart to remove another meal tray.

c. Surveyor stopped Staff A and asked if he/she had noticed the "Special Contact Precaution" isolation sign for Patient #1. Staff A responded he/she was not aware of the "Special Contact Precaution" sign posted on Patient #1's door.

2. Review of Patient #1's medical record on 12/21/10 revealed a Physician order dated 12/18/10 at 12:20 PM that revealed in part, "...Pt [Patient] is known MRSA [Methicillin Resistant Staphylococcus Aureus] + [positive] (nares). Place pt in special contact precautions..."

3. Review of CAH policy titled "Contact and Special contact Precautions" dated 6/10 stated in part, "...use contact precautions or special contact precautions for specified patients known or suspected to infected with microorganisms that can be transmitted by direct contact with the patient or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment...Examples of such illness include ...MRSA...Procedure: Place in private room, wear gloves when entering room and during the course of providing care for a patient After removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments ....Always wear a gown if you anticipate that your clothing will have contact with the patient, environmental surfaces or items in the patient's room..."

4. Review of Staff A's personnel file showed "Infection Control Orientation" completed on 6/30/08 to include in part, "...Isolation Precautions; Contact and Special contact precautions..."

5. During an interview on 12/21/10 at 3:45 PM, Staff A stated he/she did not see the Special Contact Precaution sign, "I know better than to enter an isolation room." Staff A stated he/she changed into clean clothing and reported the incident to the Infection Control Nurse for further advice.

I. Based on observation, review of documents, and interviews the Critical Access Hospital (CAH) dietary staff failed to serve the physician ordered therapeutic diet for 1 of 3 patient's (Patient #1). The CAH administrative staff reported a census of 3 inpatients and an average of 12 acute inpatients per month.

Failure to serve the correct therapeutic diet ordered by the physician could potentially result in multiple patient complications including choking, aspiration, drug nutrient interaction, and death.

Findings include:

I. Based on observation, review of documents, and interviews the Critical Access Hospital (CAH) dietary staff failed to serve the physician ordered therapeutic diet for 1 of 3 patient's (Patient #1). The CAH administrative staff reported a census of 1 acute and 2 skilled inpatients, with an average of 12 acute inpatients per month.

Failure to serve the correct therapeutic diet ordered by the physician could potentially result in multiple patient complications including choking, aspiration, drug nutrient interaction, and death.

Findings include:

1. An observation on 12/21/10 at 7:35 AM showed Patient #1 received a regular, low sodium diet. Patient #1 breakfast tray consisted of sausage links, pancakes, toast, and coffee.

2. Review of Patient #1's medical record on 12/21/10 revealed a physician order dated 12/18/10 at 4:00 PM for a regular diet, no added sodium, with ground meat.

3. Review of the Dietary Policy & Procedure titled "Patient Food Preferences"; dated 5/25/10 showed in part, " ...Diet restrictions ordered by the physician will be considered when diet is served."

4. During an interview on 12/21/10 at 10:50 AM, Staff A, Dietary Manager stated he/she reminded the staff to assure placement of the correct diet on the correct tray prior to leaving the kitchen.
5. During an interview and observation on 12/21/10 at 7:40 AM, Staff E, Registered Nurse, confirmed Patient #1's breakfast tray consisted of sausage links, pancakes, toast, and coffee. At the time of the observation, Patient #1 stated he/she had a swallowing problem, and required ground meat.
During a follow up interview on 12/21/10 at 10:30 AM, Staff E stated, in the past, the meal trays had the diet slip on the tray (the diet slip explains the type of diet the patient should receive). However, the dietary staff no longer places the diet slip on patient trays, now they only put the patient ' s room number on the tray. Staff E confirmed, he/she gave the breakfast tray to the patient without verifying that the tray belonged to Patient #1 or that the tray contained the correct diet for Patient #1.

II. Based on observation, review of Critical Access Hospital (CAH) documents and interviews revealed the CAH dietary staff failed to ensure the dishwasher maintained the National Safety Standard of water temperature of 120 degrees (? ). The CAH administration reported a census of 3 patients.

Failure to follow the National Safety Standard of 120? for the water temperature could potentially decrease the effectiveness of the cleaning cycle of the dishwasher.

Findings include:

1. Observation on 12/20/10 at 3:50 PM showed the dishwasher temperature was 100? while running a load of dishes. Staff B, Dietary Aide, stated the temperature of the water was not very high due to a broken water heater. Additional observation revealed instructions on the outside of the dishwasher read in part, "...Minimum wash temperature 120? and Minimum rinse temperature 120? ..."

2. Review of CAH policy titled "Dish Machine Operation" effective 11/1/10 on 12/21/10 revealed in part, "...Ideal temperature is 125 degrees or greater". On 12/21/10 Staff A, Dietary Manager wrote on the policy, "Everything I find refers to 120-140* as temperature for washing dishes in dishwasher".

Review of the "Temperature chart for Equipment" dated December 2010 revealed from 12/9/10 through 12/20/10 temperatures for the dishwasher rinse cycle ranged from 85 to 102? .

Review of the "Owners manual for the American Dish Service" undated revealed in part, "...temperatures below 120? or above 150? create result problems, problems you cannot correct with more soap or more water".

3. During an interview on 12/21/10 at 8:00 AM, Staff A, Dietary Manager, stated the water heater to the dishwasher was not working. The dishwasher was now on the main hospital water heater and due to patient safety; the water temperature could not be set above 120?.

a. During an interview on 12/20/10 at 2:20 PM, the Maintenance Supervisor stated the administration ordered the boiler (water heater) for the kitchen. Review of a purchase order dated 12/15/10 confirmed the CAH ordered a ThermoDyne single wall water heater.

b. During a phone interview on 12/22/10 at 8:13 AM, the Dishwasher Service Representative stated the National Public Health and Safety committee set the standard operational temperature for the chemical dishwashers at 120? . The chemical dishwasher operates at its maximum capacity when the water temperature is at a minimum of 120? .

4. Follow up observation on 12/22/10 at 9:00 AM, revealed Staff C, Dietary Cook, washed dishes in the 3-compartment sink according to policy. Staff A, stated maintenance was in the process of installing a temporary water heater for the dishwasher until the permanent water heater arrives.

Follow up observation on 12/22/10 at 2:30, revealed the dishwasher water temperature was 122? , Staff A stated the maintenance staff had installed the temporary water heater.