HospitalInspections.org

Based on review of documents and staff interviews the CAH (Critical Access Hospital) failed to ensure the medical staff approved the blood bank agreement.

Failure to ensure the medical staff approved the Blood Bank agreement could potentially result in the lack of availability of all blood products used to effectively treat emergency patients.

Findings include:

1. Review of a document titled, "Blood Supply and Services Agreement" dated 3/12/15 lacked documented evidence the medical staff approved the Bloody Supply and Services Agreement.

2. During an interview on 8/11/15 at 9:00 AM, Staff X, the Director of Ancillary Services agreed the CAH's Blood Supply and Services Agreement lacked the medical staff approval of the agreement.

I. Based on observation, review of policies, and staff interviews the CAH (Critical Access Hospital) failed to ensure staff cleaned and sanitized environmental surfaces and equipment during 1 of 1 patient's wound dressing change. (Patient #8) The CAH administrative staff reported a censes of 6 inpatients at the time of the survey.

Failure to ensure staff cleaned and sanitized the environmental surface area and equipment used during a patient's wound dressing change could potentially result in cross contamination of bacteria organisms from the environment surfaces and equipment to the patient's wound during the dressing change. Cross contamination of bacterial organisms during a wound dressing change could potentially result in a severe wound infection, severe illness, and/or death.

Findings include:

1. Review of the policy titled, "Dressing Change", dated 9/2014 stated in part, "...Dressing will be changed by using aseptic technique..."

2. During an observation and interview on 8/11/15 at 11:30 AM, showed Registered Nurse (RN) F without cleaning and sanitizing Patient #8's bedside table RN F placed clean wound dressing supplies directly onto the potentially contaminated bedside table next to Patient #8. RN F removed one pair of scissors from a pocket on her clothing. RN F without cleaning and sanitizing the potentially contaminated pair of scissors, RN F used the scissors to cut clean dressing material. Staff E, the Manager of the Emergency Department and Inpatient unit acknowledged RN F did not clean and sanitize Patient 8's bedside table before she placed the clean dressing supplies onto the potentially contaminated bedside table. Staff E agreed RN F used potentially contaminated scissors to cut the clean dressing material. RN F stated her scissors were last cleaned on 8/10/15.

3. During an interview on 8/12/15 at 3:15 with Staff B, the Clinical Support Director/Infection Preventionist agreed during a wound dressing change the work surface needs to be cleaned prior to use and if scissors are used they should also be cleaned prior to the wound dressing change procedure.



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II. Based on observations, review of policy, documents, and staff interviews, the Critical Access Hospital (CAH) Food and Nutrition Services (FNS) department failed to ensure staff used good hand hygiene practices during food handling/preparation and patient meal service. The administrative staff identified a census of 6 patients and the Interim FNS Director identified dietary staff provided an average of 27 patient meals daily.

Failure to ensure staff performed hand sanitation and donned clean gloves during meal service and food handling could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

1. The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, required gloves to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation and hands must be washed before donning gloves when working with food.

2. Observation during food preparation and meal service on 8/10/15, from 11:30 AM to 12:08 PM showed Staff K, Cook, donned gloves and proceeded to measure food temperatures. Staff K, Cook touched multiple surfaces, including but not limited to scissors, refrigerator door handle, steamer door handle, pot holders and plate/plate and base warmer unit handle. Observation showed Staff K Cook without sanitizing hands and donning clean gloves Staff K began plating food for the patient's meal tray. Staff K Cook wearing the same potentially contaminated gloves touched a taco salad shell, cubed potatoes, corn and General Tso chicken nuggets on the patient's plate.

3. Observation during food preparation and meal service on 8/11/15, from 11:30 AM to 11:51 AM showed Staff M, Cook, donned gloves and proceeded to measure food temperatures. Staff M, Cook touched multiple surfaces, including but not limited to, steamer door handle, microwave, bag of shredded cheese, plate/plate base warmer unit handle, refrigerator door handle. Observation showed Staff M, Cook without sanitizing hands and donning clean gloves began plating food. Staff M, Cook wearing the same potentially contaminated gloves touched a baked potato, shredded cheese and a chicken breast.

4. During an interview on 8/12/15, at 10:10 AM, Staff I, Interim FNS Director, reported he expected FNS staff to wear disposable gloves when serving food but acknowledged when multiple surfaces are touched, the glove becomes contaminated and staff should not touch food being dished to the patient's plate. He reported FNS staff have received training on proper hand hygiene and glove use. Staff I reported Staff K and M had completed ServSafe training (a comprehensive training program on food safety) and attended a department meeting in March 2015, which covered proper glove use.

5. Review of a document identified as a department meeting record dated, March 2015, revealed the competency selected for the meeting was titled, "Proper Glove Use" and the reason for selection as "patient safety". The document showed Staff K and M participated. The document identified the performance criteria as "frequently change", with no additional information on the educational content. Review of the policy used at the meeting titled "Employee Health, Hygiene & Uniforms", approved March 2015, identified the situations which required glove use, including handling ready to eat food and serving food, however, failed to identify the need to use gloves for a single task only and the need to wash hands prior to donning.

6. During an interview on 8/12/15 at 11:00 AM, Staff D, Organization Value Director, reported all CAH staff are assigned to complete an education module titled "Hand Hygiene" on Healthstream (an electronic education program). Staff D verified Staff K and M completed the module. Review of the module content revealed it lacked content specific to glove use with food handling.

During an interview on 8/12/15, at 3:15 PM, Staff B, Clinical Support Director/Infection Control Preventionist, confirmed the identified observations of glove use with FNS staff included concerns with cross contamination. She acknowledged her past observations of FNS staff identified poor food handling practices and an opportunity for improvement with new leadership in the department.

III. Based on review of policies, documents, and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH had a system in place to monitor the contract employee's personnel records to ensure heath examinations were completed.

Failure to ensure the CAH had a system in place that included monitoring of the contracted staff personnel health examinations could potentially result in causing harm to patients in the event of an unknown staff's exposure and transmission of communicable diseases to the patients. The CAH failed to ensure 3 of 5 contracted staff had documented evidence of a health examination. (Staff I, Interim Nutrition Services Director, Staff V, Sleep Study Technician, and Staff W, Sleep Study Technician)

Findings Include:

1. Review of policy titled, " Employee Health Program " dated 8/2014 stated in part, " ...A pre-employment physical is required to be completed by the day of employment ...A health exam is required every three years ... "
Review of policy titled, " Volunteer Health/Orientation Program " dated 8/2014 stated in part, " ...Contracted staff ...will be expected to follow the same health requirements as employees ... "

2. Review of personnel records revealed the following:

a. Staff I, Interim Nutrition Services Director lacked documented evidence of a health examination.

b. Staff V, Sleep Study Technician lacked documented evidence of a health examination.

c. Staff W, Sleep Study Technician lacked documented evidence of a health examination.

3. During an interview on 8/13/15 at 8:05 AM, Staff U Employee Education Health Wellness employee acknowledged the lack of health examinations for Staff I, Staff V and Staff W.

I. Based on review of policies, documents, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Medical Staff approved the CAH's diet manual. The CAH administrative staff identified a census of 6 patients at the time of the survey. The Interim Food and Nutrition Services (FNS) Interim Director reported the department provided an average of 27 patient meals daily.

Failure to ensure the Medical Staff approved the diet manual, intended to establish a common language and practice for physicians and other healthcare professionals to use when providing nutritional care to patients, could potentially result in inappropriate therapeutic diets orders and inappropriate food/beverages served to patients, leading to the provision of inadequate or excess nutrients and complications in their care.

Findings included:

1. Review of a Food and Nutrition Services policy titled "Modified Diets and Diet Manual", approved 8/2014, revealed it failed to identify the current approved diet manual.

2. During an interview on 8/10/15, at 10:45 AM, Staff J, Dietary Lead, identified the CAH's current diet manual titled, "Simplified Diet Manual 11th edition." Review of the CAH's Simplified Diet Manual revealed Staff O's, Consultant Dietitian, undated signature appeared on the inside cover of the manual. However, the manual lacked documented evidence that showed the medical staff approved the diet manual. Staff J reported she would check with Staff O to see if she knew anything about the approval of the manual.

During an interview on 8/11/15, at 10:00 AM, Staff O, reported the "Simplified Diet Manual, 11th edition" as the current CAH diet manual and believed it had been approved by the medical staff, but unsure of when or how this was documented.

3. On 8/11/15, at 7:30 AM, Staff C, Chief Nursing Officer, provided documents titled "Annual Review of Policy and Procedure Tracking Sheet" dated 8/1/14 and "Medical Staff Meeting" minutes, dated 8/12/14. Review of the documents showed approval of the FNS policies, including the policy titled "Modified Diets and Diet Manual", but lacked documented evidence of the specific diet manual approved for use.


II. Based on observation, document review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to plan defined food portions, for all items on the select therapeutic menus, and provide a planned non-select menu, with defined food portions for patients unable to complete a select menu.

Failure to provide a planned menu with defined food portions for dietary staff to follow could potentially result in inappropriate food/beverages served to patients, leading to the provision of inadequate or excess nutrients and complications in their care.

Findings include:

1. During an interview on 8/10/15, at 10:40 AM, Staff J, Dietary Lead reported a diet clerk visits patients daily to obtain patient meal selections from options planned to meet their specific diet order. Staff J reported the department did not have a planned non-select menu in the event a patient is unable to select or declined to make their own meal selections. Staff J reported in this case, dietary staff would make selections for them, based on any known preferences, but the department lacked specific guidelines of appropriate choices for each diet type.

2. Review of the daily menu selector sheets for breakfast, lunch and supper, planned for the various therapeutic diets offered by the CAH, revealed the selector sheets did not define portion sizes for all items and did not indicate which items would be served, in the event a patient failed to make their own selections.

3. Observation during the patient lunch meal service on 8/10/15, beginning at 11:45 AM, revealed Staff K, Cook and Staff L, Cook, began to assemble patient meals. Staff K reported 2 patients selected the taco salad from the cafeteria menu. The diet order list identified one of the patients required a restricted diet with consistent carbohydrate, low cholesterol, low fat and no added salt and the other patient on a regular diet. Staff K obtained a taco salad (fried taco shell, lettuce, taco meat, refried beans and cheese) and placed on the meal tray for the patient on a restricted diet. Staff L asked this surveyor if the patient could have salsa, and when an answer was declined, she placed a salsa cup on the patient's tray. After intervention from Staff I, Interim FNS Director, Staff K removed the taco salad from the patients tray and replaced it with a taco salad consisting only of lettuce, refried beans and cheese.

4. During an interview on 8/10/15, at 1:40 PM, Staff L, Cook, reported if a patient does not make their own selections for a meal, dietary staff would ask family or the nurse what would be appropriate food selections for the patient. She reported patients are offered items from the cafeteria menu, in addition to the items on the meal selector sheets. Staff K acknowledged the department does not have a planned non-select menu or specific guidelines on how cafeteria items might be included on the various therapeutic diets.

During an interview on 8/10/15, at 1:45 PM, Staff I confirmed the department did not have a planned non-select menu.

During a follow-up interview on 8/10/15, at 3:00 PM, Staff I reported he had located a menu notebook which appeared to be a non-select menu. Staff I reported it was apparent the dietary staff did not know about it or utilized it and confirmed the menus lacked defined portion sizes for all items and the menus had no approval signature or date. Staff J, Dietary Lead present at the time, confirmed the FNS staff did not use the menus in the notebook.

During an interview on 8/11/15, at 8:00 AM, Staff N, Diet Clerk, reported when assigned to visit patient for meal selections, she offered cafeteria items to patients that seem appropriate for their specific diet order. She acknowledged there was no set reference for which cafeteria items would be appropriate on the various diets, but consulted with the cook on ingredients and check the CAH's diet manual to determine what might be appropriate or not.

During an interview on 8/11/15, at 8:45 AM, Staff M, Cook, reported, when assigned to visit patients for meal selections, she offered cafeteria items appropriate to their specific diet order. She reported there was no defined criteria for which cafeteria items would be appropriate on the various therapeutic diets, but offered them based on her common sense and knowledge of the diets. Staff M reported she did not receive good training on therapeutic diets but taught herself by referencing the CAH's diet manual.

During an interview on 8/11/15, at 10:00 AM, Staff O, Consultant Dietitian, reported she provides consulting services to the CAH. She relayed the menu system at the CAH was modeled after the menu system used in the facility where she is employed full-time. Staff O reported the menu system at the CAH should have a planned non-select menu, but could not confirm this. Staff O reported the department lacked any set criteria or reference to identify how cafeteria items might fit into the various therapeutic diets.

During an interview on 8/12/15, at 10:10 AM, Staff I reported he assumed the contracted position on an interim basis on 7/29/15. Staff I reported he helped implement the CAH's current menu system approximately 2 years ago and the department had a non-select menu in place, with defined portion sizes and recipes that included portion sizes for the patient menu, but did not know what happened to them. He acknowledged the CAH failed to have a system to identify the appropriateness of cafeteria items on therapeutic diets ordered for patients and the potential for inappropriate items being provided to patients.

Based on review of documents and staff interview the administrative staff failed to ensure the Board of Trustees (the Governing Body) reviewed the Critical Access Hospital (CAH) contract agreements annually. Staff reported a patient census of 6 at the time of the survey.

Failure to ensure the Board of Trustees reviewed all the contract agreements annually at the CAH could potentially result in the contract agreements not meeting the needs of the patients.

Findings include:

1. Review of the documents titled, "Board of Trustees Meeting Minutes" dated August 18 2014 through August 20 2015 lacked documented evidence of an annual review of the CAH contract agreements.

2. During an interview on 8/12/15 at 2:30 PM the Chief Executive Officer acknowledged the Board of Trustees did not review the CAH contract agreements annually. The Chief Executive Officer reported he reviewed all the CAH contract agreements and was not aware the Board of Trustees should review all the CAH contract agreements annually.

Based on observation, review of policies, and staff interviews revealed the Critical Access Hospital (CAH) administrative staff failed to have a system in place to ensure old medical records, keys to access the shred bins and locked cabinets that held patient information were secured and protected from unauthorized use.

Failure to ensure the CAH had a system in place to secure old medical records, keys to access the shred containers throughout the CAH in order to protect all patient information in the shred containers and locked cabinets could potentially result in misuse of patient information and/or stolen patient identities by unauthorized personal.

Findings include:

1. Review of a policy titled, "Minimum Necessary Use or Disclosure Protected Health Information" dated 9/2014 stated in part, "...Organization will make "reasonable efforts" to limit the use, disclosure, access to...protected health information...to the minimum necessary ... "

2. During an interview on 8/10/15 at 4:00 PM, the Support Services Manager reported the evening Environmental Services lead employee had procession of a key used to open all the shred containers throughout the hospital. The Support Services Manager reported twice weekly, the evening Environmental Services employee used his key to open the shred containers throughout the CAH to empty the contents into 95 gallon shred containers. The Support Services Manager reported he and all the Environmental Services staff had access to a key to open the shred containers. The Support Services Manager reported the key is stored in lock box in the Environmental Services department.

During an interview and observation on 8/11/15 at 2:45 PM in the Environmental Services department showed a locked box that held multiple keys. The Support Services Manager identified the key in the lock box used to open all the shred containers throughout the CAH. When asked if there is a system to monitor the usage of the keys in the lock box the Support Services Manager reported all Environmental Services staff had access to the locked key box without signing a key in or out. The Support Services Manager acknowledged all Environmental Services staff could access patient information in the shred containers without the knowledge of the administrative staff.

During an interview on 8/11/15 at 10:00 AM, the Consultant Dietician reported she maintained outpatient medical records locked in a cabinet in her office (located in the Materials Management department). When asked if she was the only person with pocession of the key to the locked cabinet, the Consultant Dietician reported the Materials Management Technicians had access to the key to the locked cabinet that held the outpatient medical records.

During an interview on 8/11/15 at 1:30 PM Staff R and Staff S, Information Systems Staff reported the Materials Management staff, the Plant Operations staff and the Environmental Services staff would not be considered staff that would need access to patient information.

During an interview and observation on 8/12/15 at 7:40 AM in the Consultant Dietician's office with Staff P, Materials Management Lead and Staff Q, Materials Management Technician revealed one unlocked cabinet that held approximately 50 patient medical records dated from 2008 through 2012. Staff P and Staff Q reported both of them had access to the locked cabinet that held outpatient medical records in the Consultant Dietician's office. Staff P and Staff Q reported they had access to the locked cabinet because the locked cabinet is shared with the Materials Management staff. Observation showed approximately 80 outpatient medical records were in the locked cabinet. The outpatient medical records revealed the patients name, medical diagnosis, laboratory results, medications, etc.

During an interview on 8/11/15 at 3:55 PM the Chief Financial Officer reported she was unaware the Materials Management employees had access to outpatient medical records in the Consultant Dietician's office. The Chief Financial Officer reported the Materials Management Technicians should not have access to outpatient health information.

Based on review of documents and staff interview the administrative staff failed to delineate privileges for Radiology and Surgical Technicians who assisted Practitioner A during surgical procedures. Staff AA, Radiology Technician assisted Practitioner A during with 115 of 115 surgical procedures from August 2014 through August 2015. Staff BB, Surgical Technician assisted Practitioner A during 24 of 115 surgical procedures from August 2014 through August 2015.

Failure to ensure the administrative staff delineated privileges for 1 of 1 Radiology Technician and 1 of 1 Surgical Technician prior to assisting Practitioner A during surgical procedures could potentially result in patients receiving surgical interventions from unqualified professionals.

Findings include:

1. Review of a document titled, "Medical Staff Bylaws" dated January 19, 2015 stated in part, " ...A member of the Medical Staff may exercise only those clinical privileges granted in accordance with these Bylaws ..."

2. Review of a documents titled, "Operating Room Log" showed from August 2014 through August 2015, Staff AA, Radiology Technician assisted during 115 of 115 surgical procedures with Practitioner A.

Review of a documents titled, "Operating Room Log" showed from August 2014 through August 2015, Staff BB, Surgical Technician assisted during 24 of 115 surgical procedures with Practitioner A.

3. Review of a document titled, "Practitioner Surgical Privileges" in the surgery department lacked documented evidence Staff AA and Staff BB had privileges to assist Practitioner A during surgical procedures.

4. Review of Staff AA's and Staff BB's personnel records lacked documented evidence of privileges to assist Practitioner A during surgical procedures.

5. During an interview on 8/11/15 at 3:15 PM Staff T, Operating Room Outpatient Services Leader acknowledged Staff AA Radiology Technician and Staff BB Surgical Technician did not have privileges, although both scrubbed in to assist Practitioner A during surgical procedures.

Based on review of documents and staff interview the administrative staff failed to ensure 2 of 41 patient care service departments were evaluated through the quality assurance program process at the Critical Care Access Hospital (CAH).

Failure to ensure all patients service departments submitted a quality activity report for evaluation of quality activities to the Quality Improvement Committee at the CAH could potentially result the inability to evaluate the quality of care for the patients.

Findings include:

1. Review of a document titled, "Quality Improvement Reporting Schedule" no date stated in part, "...Central Sterile...Anesthesia ..."

2. Review of documents titled, "Quality Improvement Meeting Minutes" from 8/19/13 through 8/10/15 failed to show Central Sterile and Anesthesia quality activity reports.

3. Review of a document titled, Quality Improvement Plan " dated July 2014 - June 2015 stated in part, " ...The primary goal of the Quality Improvement Plan is to provide care that is safe, effective, patient centered, timely, and efficient ...ensure participation from all departments and services including contracted services ... "

4. During an interview on 8/12/15 at 7:20 AM, the Organizational Value Director acknowledged the Central Sterile and Anesthesia departments failed to submit quality activity reports.

Based on review of policies, documents, medical records, and staff interview, the Critical Access Hospital (CAH) failed to ensure physicians provided a written order for specialized rehabilitation services for 1 of 5 closed swing bed patients. (Patient #2) The CAH staff identified an average daily census of 2 swing bed patients.

Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehabilitation services appropriate to their medical condition.

Findings include:

1. Review of policies revealed the lack of a policy that a physician must provide a written order for specialized rehabilitation services.

2. Review of Patient #2's medical record revealed the following:

a. A document titled, "Orders Report 6/30/15" included in part, "...Consult PT (Physical Therapy)... Practitioner B, Advanced Registered Nurse Practitioner (ARNP)..." The document failed to show Practitioner C ordered PT for Patient #2 on 6/30/15.

b. A document titled, "History and Physicial" stated in part, "...Continue aggressive PT...Practitioner C signed on 7/2/15..."

3. During an interview on 8/13/15 at 10:35 AM, Staff C, Chief Nursing Officer (CNO), acknowledged Patient #2's medical records lacked a physician's order for specialized rehabilitation services for the patients and also acknowledged the lack of a policy that a physician must provide a written order for specialized rehabilitation services.