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Based on record review and interview, the facility failed to analyze its emergency water needs to determine if it had sufficient potable water on hand to ensure the safety of patients in non-medical emergencies.

Findings include:

Review of the American Water Works Association and CDC Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities, Version 2, 2012 revealed under the heading for Water Use Audit, section 6.1, four bullets for what the facility needs to do as part of the development of an emergency response plan. One of these bullets reads "Develop working estimates of the quantity and quality of water required to continue operation of essential functions and to meet the emergency demands." In addition, Section 7.1 relates, in part, "... a normally active person needs at least one-half gallon of water daily just for drinking.... Children, nursing mothers, and ill people need more water.... A medical emergency might require additional water...."

During tour of the main kitchen with Staff G, (Manager of Nutritional Services), on 12/15/15, Staff G related that they have a 100 gallon emergency water supply; however,Staff G was not aware of any analysis the facility had performed (regarding emergency water needs). Staff G stated that the average [daily] census is 10 inpatients.

Based on observation and interview it was determined that the Critical Access Hospital failed to provide a safe emergency department for patient's and staff by not preventing access by unauthorized individual to the department.

Findings include:

Observation on 12/15/15 during tour of the Emergency Department revealed an unlocked/unsecured door leading from an upstairs stairwell and outside door directly into the Emergency Room hallway leading to the patient care areas of the Emergency Department. This unlocked door provides internal and external access to the Emergency Department by unauthorized individuals. This unlocked door was confirmed by Staff E (Emergency Room Director) during tour of the Emergency Room on 12/15/15 and again on 12/16/15.

Based on observation and interview, the CAH failed to ensure that drugs and biologicals that are outdated are not available for patient use in multiple outpatient locations.

Findings include:

Observation during tour of Adult Internal Medicine on 12/16/15 at 9:10 a.m. revealed the following biologic to be expired:

4 culturette swabs with an expiration date of 11/30/15.

Observation during tour of Surgical Associates/Kane Center on 12/16/15 at 10:15 a.m. revealed the following medication and biologic to be expired:

6 boxes of Vesicare 5 mg tablets with an expiration date of 11/30/15
3 bottles of Siemens Uristix test strips with an expiration date of 11/30/15

Interview with Staff B (Infection Control Manager) and Staff C (Physician Practice Administration) on 12/16/15 at the time of tour confirmed the above findings.

Observation during tour of Valley Regional Primary Care on 12/17/15 at 8:45 a.m. revealed the following medications to be expired:

6 boxes on Anoro Ellipta 6.25 mcg/25 mcg with an expiration date of 11/30/15;
1 box of Bero Ellipta 100 mcg/25 mcg with an expiration date of 10/31/15;
Tudorza Pressair 400 mcg per actuation: 2 boxes with an expiration date of 8/31/15;
4 boxes with an expiration date of 9/30/2015, and 3 boxes with an expiration date of 11/30/15.

Interview with Staff B and Staff C on 12/17/15 at 8:45 a.m. confirmed the above finding.

Based on observation, interview and record review it was determined that the Critical Access Hospital failed to maintain a sanitary environment in the main kitchen, and failed to follow and upkeep equipment for infection control practices in two outpatient/satellite practices.

Findings include:


27714

During tour of Adult Internal Medicine on 12/16/15 at 8:55 am, the Freestyle Life glucose meter was observed to have blood on the back and side of the meter. There was also a paper label adhered to the back of the meter preventing proper cleaning.

Interview with Staff B (Infection Control Manager) and Staff C (Physician Practice Administration) confirmed there was blood on the back and side of the glucose meter indicating it had not been cleaned after the last use. Staff B and C also confirmed there should not be a paper label attached to the meter for cleaning purposes. Interview with Staff D (Medical Assistant) confirmed it is the CAH's procedure to clean and disinfect the meter after every use and that the glucose meter had not been cleaned after the last use.

The CAH's procedure titled "Cleaning and Disinfection of Equipment in the Outpatient Setting", states at Procedure, 3a "Any non critical item that could be contaminated with blood or body fluid will be cleaned after each use (glucometer, INR machine, other point of care item)."

During tour of Adult Internal Medicine Practice on 12/16/15 at 9:10 a.m., it was observed that the exam table in room 111 was worn on two corners showing the inside material.

During tour of the Valley Regional Pediatric practice on 12/16/15 at 9:45 a.m., it was observed that the exam table in Room 3 had an approximate two inch tear on the top. Breaches in the integrity of the exam tables can prevent proper cleaning and infection control prevention.

Interview with Staff B and Staff C on 12/16/15 confirmed the above findings.


16285

Review of the facility's Nutritional Services policy issued 8/15/88, Employee Guidelines: Infection Control Practices, revealed that the Procedure includes, in part, "Use a spatula or tongs, or wear disposable gloves when handling food.... store serving utensils: In food with handle extending out of the food, ...."

During tour of the main kitchen on 12/15/15 with Staff G, (Interim Manager of Nutritional Services), it was observed that the flour and sugar bins were not dated as to the age of their contents. Both bins had a scoop in them, and the scoop in the flour bin was positioned with the handle up. However the handle of the scoop in the sugar bin was in contact with the sugar, and Staff G lifted it out with his bare hand. The powered sugar bin in dry storage also was not dated as to the age of its contents; that bin was observed to have an inside scoop holder.

Based on record review and interview, it was determined that the facility failed to include services provided under agreements in their Quality Assurance review and failed to ensure that the results of a criminal background check were reviewed before employees under service arrangement had direct contact with patients.

Findings include:

Review of the Agreement for Massage Therapy Services between the facility and a massage therapist, revealed that this agreement commenced on 9/1/15, and Exhibit A, which lists some requirements for each person providing service under this agreement, states, in part, "A recent satisfactory Criminal Background check (within 60 days of agreement commencement)...." thereby allowing the therapist to have direct patient contact prior to completion of a criminal background check.

Review of the Facilities Use Agreement made 7/10/15 between the facility and another party, for Hospital use of the other party's pool facilities, revealed that this agreement does not address delegation of infection control oversight and responsibility for Hospital activities at the pool facilities.

Interview with Staff H, (Head of Quality Assurance), on 12/17/15 revealed that contracts are reviewed by contract management before they are signed, but contracted services are not reviewed by Quality Assurance.

Patient #15
Record review on 12/17/15 revealed that Patient #15 was admitted to acute services 9/5/15 through 9/9/15 when Patient #15 was transferred to SNF (Swing Level Care). Review of Patient#15's History and Physical revealed "Disposition: SNF". Further review revealed the medical record record lacked a distinct physician order discharging the patient from actue care and admitting to Swing Bed status.

Interview on 12/17/15 with Staff A, (RN), Staff A confirmed the absence of a distinct order to discharge patient from acute care and admit the patient to Swing Bed status.






















16285

Based on record review and interview, it was determined that the facility failed to ensure that medical records were accurately written and/or complete for 4 patients in a survey sample of 55 patients. (Patient identifiers are #15, #18, #21, and #22.)

Findings include:

Patient #18
Review of the facility's Detail Death Listing revealed that this patient experienced a cardiac arrest and expired on 5/22/15. Review of the Nurse's Notes Con't document revealed conflicting documentation of death under Outcome, with Time of death 21:14, but ME [medical examiner] notified 09:55 [i.e. hours before]; and on the Organ and Tissue Donation form the Time of Death is recorded as 9:15 a.m.

Patient #21
Record review revealed the patient was admitted to Swing Level Care on 3/15/15. Review of the current care plan revealed last review on 12/17/15 at 09:04, but the "Expect Achv" goal date for the patient's tissue integrity to improve or return to baseline was 7/29/15. The facility failed to update the tissue integrity goal/date at time of review. This finding was reviewed with nursing Staff A during the afternoon on 12/17/15.

Patient #22
Record review revealed the patient was moved from acute bed status to swing bed status on 12/15/15. Review of physician orders for the period 12/11/15 - 12/16/15 revealed that the order for this move was written as "SNF (SWING LEVEL CARE)" with no distinct order to discharge the patient from the Acute Hospital stay.