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Based on observation, review of Material Safety Data Sheets (MSDSs), and staff interview, the Critical Access Hospital (CAH) failed to safely store hazardous chemicals for 1 of 3 days of survey (March 29, 2017). Failure to safely store hazardous chemicals may result in cognitively impaired patients sustaining an injury.

Findings include:

Review of the CAH's MSDSs occurred on 03/29/17 and identified the following:
* Super HDQ Neutral: ". . . Corrosive . . . Causes irreversible eye damage . . . Causes skin burns . . . harmful if swallowed . . . inhalation of spray mist may cause respiratory irritation . . ."
* Penner Whirlpool Disinfectant: ". . . May cause eye irritation and skin irritation with prolonged exposure. Can be harmful if swallowed or if spray mist is inhaled. . . ."
* Cen Kleen IV: ". . . May cause . . . nausea and vomiting . . . Eye contact causes painful damage and corneal irritation . . . skin contact can cause redness, burns, pain and blistering . . ."
* Windex Glass Cleaner: "Avoid contact with eyes. . . ."
* Capri - Original: ". . . Causes serious eye irritation . . ."
* Virex 128: ". . . Corrosive. Causes irreversible eye damage. Causes skin burns. Harmful if inhaled, swallowed or absorbed through skin. . . ."
* Clorox: ". . . Causes substantial but temporary eye injury. May irritate skin. May cause nausea and vomiting if ingested. Exposure to vapor or mist may irritate nose, throat and lungs. . . ."

Observation of the environment occurred on 03/29/17 at 7:45 a.m. with two environmental services staff members (#1 and #2) and showed the following hazardous chemicals stored in unlocked areas:
* In a tub room cabinet with the door ajar: Super HDQ Neutral, Whirlpool Disinfectant, and Cen-Clean IV
* On a counter in the beauty shop: Windex spray
* In the soiled utility room: Whirlpool Disinfectant, Maximum Capri Original spray, Virex spray, and Clorox.

During the observation, an environmental staff member (#1) confirmed staff should store the above listed chemicals in locked rooms or cabinets.

SAFETY DEVICES ON FAUCETS

1. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to provide safety equipment to prevent back flow of contaminated water into the potable (drinking) water system of the facility for 2 of 4 sinks with hoses attached to the faucets (beauty shop and storeroom adjacent to physical therapy). Failure to provide safety devices may result in contamination of the water supply.

Findings include:

Observation of the environment occurred on 03/29/17 at 7:45 a.m. with two environmental services staff members (#1 and #2) and showed the following:
* In the beauty shop: A shampoo sink with the hose resting on the bottom of the sink and no safety device on the faucet
* In the storeroom adjacent to the physical therapy department: A large utility sink with a hose attached to the faucet and resting at the bottom of the sink and no safety device on the faucet.

During the observation, an environmental staff member (#1) confirmed the above faucets lacked safety devices.

MAINTENANCE OF STORAGE CABINET

2. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure staff maintained 1 of 1 storage cabinet in the soiled utility room. Failure to maintain the cabinet created an uncleanable surface which may result in the spread of infections in the CAH.

Findings include:

Observation of the environment occurred on 03/29/17 at 7:45 a.m. with two environmental staff members (#1 and #2) and showed a metal cabinet under the sink in the soiled utility room. Observation showed cleaning supplies stored in the cabinet and revealed rust on the edges and the inside of the cabinet doors and covering the left inside wall.

During the observation, the staff members (#1 and #2) confirmed the rust created an uncleanable surface.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure an orderly environment in 1 of 1 central supply room. Failure to ensure staff stored supplies off the floor may result in rodent or water damage to the supplies.

Findings include:

Observation in the central supply room and sterilizing room occurred on 03/27/17 at 1:45 p.m. with a sterilizing clerk and showed two mouse traps in each room. When asked, the staff member stated she had not seen any mice or evidence of mice, but "heard" staff had caught a mouse the day before.

Observation in the central supply room showed multiple boxes stored on the floor including: three boxes of incontinence briefs, 15 boxes of disposable gloves, two boxes of paper used to cover examination tables, two boxes of paper cups, two boxes of Sani-wipes, one box of resuscitation bags, two boxes of water bottles, two boxes of incontinence pads, and one box of blankets.

A second observation in the central supply room occurred on the morning of 03/28/17 with an administrative nurse (#4). The nurse confirmed staff should store supplies off the floor.

MEDICAL STAFF RECOMMENDATION FOR REAPPOINTMENT

1. Based on bylaws review, record review, and staff interview, the governing body failed to ensure a physician member of the medical staff recommended reappointment for 1 of 2 physicians' (Physician #1) credentialing records reviewed. Failure to have a physician recommend reappointment of physicians to the medical staff placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Bylaws, Rules and Regulations Medical and Dental Staff St. Luke's Hospital" occurred on 03/27/17 at 3:05 p.m. These bylaws, dated 11/29/11, stated, ". . .
Article III - Membership
Section 3. Terms of Appointment
Subsection 1
Appointment to the medical and dental staff shall be made by the governing body after recommendations by the medical staff . . .
Section 4. Procedures for Appointment . . .
Subsection 2
The medical staff shall investigate the character, qualifications, and standing of the applicant and shall submit a report of the findings at the next regular meeting of the staff . . ."

Reviewed on 03/28/17, the credentialing record for Physician #1 included a form dated 10/01/15 signed by a nurse practitioner and a governing board member granting privileges in family medicine for Physician #1.

During an interview on 03/29/17 at 9:30 a.m., a staff member responsible for credentialing (#6) confirmed a physician member of the medical staff had not recommended approval of Physician #1 for reappointment on 10/01/15.


APPOINTMENT TO MEDICAL STAFF

2. Based on rules and regulations review, bylaws review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment to the medical staff for 1 of 1 telemedicine entity's physicians (Telemedicine Entity #1) providing electrocardiogram (EKG) interpretation services to the CAH's patients. Failure to appoint practitioners to the medical staff placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Rules and Regulations Medical and Dental Staff St. Luke's Hospital" occurred on 03/27/17 at 3:35 p.m. This document, dated 11/29/11, stated, ". . . 7. Patients may be treated only by physicians who have submitted proper credentials and have been duly appointed membership on the medical staff. . . ."

Review of the governing body's "Bylaws of St. Luke's Hospital (A Non-Profit Corporation)" occurred on 03/27/17 at 3:50 p.m. These bylaws, dated 11/29/11, stated, ". . .
Article VI - Medical Staff
Section 1 - Appointment: The Board of Directors shall appoint for the hospital a medical staff which may be composed of the following:
(a) Physicians licensed in North Dakota to practice medicine. Privileges may be granted each physician by the Board of Directors after consultation with the medical staff. . . ."

During an interview on 03/28/17 at 3:05 p.m., an administrative staff member (#7) stated the CAH used the services of Telemedicine Entity #1 for EKG interpretation.

Upon request on 03/28/17 at 4:00 p.m., the CAH failed to provide evidence the medical staff recommended and the governing body approved appointment to the CAH's medical staff physicians from Telemedicine Entity #1.

During an interview on 03/28/17 at 4:30 p.m., a staff member responsible for credentialing (#6) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of the physicians from Telemedicine Entity #1 to the CAH's medical staff.


APPROVAL OF PRIVILEGES

3. Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the approval of appropriate clinical privileges for 2 of 8 medical staff members' (Providers #2 and #3) files reviewed. Failure to ensure the approval of appropriate clinical privileges for medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the "Bylaws, Rules and Regulations Medical and Dental Staff St. Luke's Hospital" occurred on 03/27/17 at 3:05 p.m. These bylaws, dated 11/29/11, stated, ". . .
Article IV Divisions of the Medical and Dental Staff . . .
Section 6. The Dental Staff . . .
Section 7. Allied Health Staff
The medical staff will approve credentials on professional staff relating to patient care in allied health fields, etc. . . . CRNA's [certified registered nurse anesthetists] . . . The Credential Committee will check privilege list to verify appropriated [sic] privileges for levels of education, experience, and training . . ."

Review of the governing body's "Bylaws of St. Luke's Hospital (A Non-Profit Corporation)" occurred on 03/27/17 at 3:50 p.m. These bylaws, dated 11/29/11, stated, ". . .
Article VI - Medical Staff
Section 1 - Appointment: The Board of Directors shall appoint for the hospital a medical staff which may be composed of the following: . . .
(b) Dentists licensed in North Dakota to practice dentistry. Privileges may be granted each dentist by the Board of Directors after consultation with the Medical Staff. . . ."

Review of a listing of the CAH's medical staff occurred on 03/27/17. This undated document listed, ". . .
Courtesy Staff Members
[Name of Provider #2], DDS [Dental Surgery] . . .
Other Credentialed Personnel . . .
[Name of Provider #3], CRNA . . ."

Reviewed on 03/29/17, the credentialing records for Providers #2 and #3 included forms, dated 10/01/15, signed by the chief of medical staff and a governing board member granting privileges in family medicine for Providers #2 and #3.

During an interview on 03/29/17 at 9:30 a.m., a staff member responsible for credentialing (#6) confirmed the medical staff and governing board had inappropriately granted family medicine privileges to Provider #2 who is a dental surgeon and Provider #3 who is a CRNA.

Based on observation, review of professional references, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed appropriate infection control practices regarding storage of equipment in 1 of 1 operating room. Failure to follow appropriate infection control practices may result in transmission of organisms and pathogens from equipment to patients.

Findings include

The Association of Perioperative Registered Nurses (AORN) clinical practice guideline, "Anesthetic Equipment," updated January 28, 2013, stated, ". . . Laryngoscope blades should be . . . protected from contamination until used. . . . blades should be stored in packages . . . to ensure the blade is protected from contamination. The storage of unpackaged laryngoscope blades is unreliable and leads to questions regarding the safe use of the blades. . . ."

The American Association of Nurse Anesthetists (AANA) document, "Infection Control Guide for Certified Registered Nurse Anesthetists [CRNA]," revised November 2012, stated, ". . . Oral Airways . . . and Laryngoscope Blades: Most oral airways . . . are disposable and should be treated as clean objects. . . . Reprocessed laryngoscope blades . . . should then be packaged and stored in a manner so that recontamination is prevented. . . . leaving such equipment loose and unpackaged in the drawer of the . . . cart is not considered an appropriate method of packaging and storage. . . . Preventive Measures: . . . Infection transmission . . . can be reduced or prevented when appropriate safeguards and precautions are implemented and must be a priority in all settings where patient care is provided. . . ."

Observation of the operating suite on 03/27/17 at 5:05 p.m. with a surgical nurse (#5) showed a laryngoscope and blade, oral airways, and packaged suction catheters on the anesthesia machine covered with a towel. During interview at this time, the nurse (#5) confirmed staff should not place the items on the machine until just prior to the start of the surgical procedure. Further observation revealed a laryngoscope and several unpackaged blades lying in a drawer of the machine. During interview at this time, the nurse (#5) confirmed staff should package the clean blades prior to storing them in the drawer.

Review of the 2017 surgical schedule identified a physician performed procedures the third Thursday of each month and last performed cases on March 16, 2017. According to that schedule, the next date the physician would perform cases would be April 20, 2017. The CAH would have improperly stored the anesthesia equipment for another three weeks.