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Based on observation, interview and document review the critical access hospital failed to monitor the temperature of the dish washer in a log according to their policy. This deficient practice had the potential for food borne illness or injury by cross-contamination through improper dish washer water sanitizing temperatures.

Findings include:

DISHWASHER

Observation 9/21/15 at 9:30 a.m. during initial tour revealed a steam/chemical dishwasher in the dietary department.

Record review of the daily temperature log from 9/1/15 to 9/21/15 revealed a "T-Stick sticker " was to be stapled to the sheet daily (measures temperatures). The log did not contain any "T-Stickers. " Record review of a policy titled "T-Sticks" dated March 2005 stated "Policy: T-Stick test strips are used to check the temperature of the dishwasher every day. The testing on the T-Stick will turn black if the correct temperature was reached during dishwashing. Test strips that have been used are stapled to a log sheet ..."

Interview 9/21/15 at 3:30 p.m. with a dietary aide (ID# K ) stated the facility does not have any "T-Stickers" anymore and when she checked off on the Temperature log she was checking that the chorine levels were adequate. The dietary aide stated she visually checks the temperature to ensure it reaches 140 degrees Fahrenheit but does not write the water temperature down.
Interview 9/23/15 at 8:15 a.m. with the Dietary Manager (ID# H) stated she thought as long as the chemicals were appropriate the temperature was not a factor. The Dietary Manager stated the hospital does not currently have any T-Sticks to measure water temperatures.
The Dietician (ID# F) acknowledged 9/23/15 at 8:40 a.m. that with a steam / chemical dishwasher temperature should be monitored daily.

Based on observation, interview and document review the critical access hospital failed to ensure multi-dose vials of medications were initialed and dated once opened and that single dose vials of medications were disposed of once opened in the nursing station pharmacy room and the wound cart. This deficient practice had the potential for patients receiving services at the hospital to receive ineffective medications.

Findings include:

Observation 9/21/15 at 9 a.m. during initial tour revealed the following:

-Nurses station medication room: (Inside a cabinet was a tray labeled "Emergency Room Tray." Inside the tray was a 20 ml(milliliter) multi-dose vial of Xylocaine(also known as Lidocaine) 2% (medication used for numbing) that had been previously opened. The vial was not dated as to when it was first opened. Also a single dose 10 ml vial of Xylocaine with epinephrine (used as a local anesthetic) had been previously opened. The vial had no preservatives.

-A wound care metal cart in a storage area: Inside the cart was a 20 ml multi-dose vial of Xylocaine 2% that had been previously opened. The vial was not dated as to when it was first opened. Also a 50 ml multi-dose vial of Lidocaine 2% was observed that had been previously opened. Someone had written on the vial 12/10/14.

The Assistant Director of Nursing (ID# A) stated the vials should be dated once opened.

Review of a policy titled "Multi-dose vials Usage", dated October 2014 stated "When multi-dose vials are opened label on the vial the date opened...The multi-dose vial must be discarded 28 days from the date opened..."

Review of the Centers for Disease Control's (CDC ' s) Position - "Protect Patients Against Preventable Harm from Improper Use of Single-dose/Single-use Vials" read in part: Vials labeled by the manufacturer as "single dose" or "single use" should only be used for a single patient. These medications typically lack antimicrobial preservatives and can become contaminated and serve as a source of infection when they are used inappropriately.

Review of a document titled "Environmental Rounds Worksheet" dated 6/26/15 stated "Medications: Open vials dated and timed as per policy=Non-compliant."

Based on observation, interview and document review the critical access hospital failed to 1) ensure the premises were free of high level dust in the emergency room and in 8 of 8 patient rooms (Room #'s 202, 204-210), and on top of the food cart; 2) failed to ensure the community shower where the medical providers shower was free of mold/black mildew; and 3) failed to ensure the flooring in the Cat Scan room was in good repair. Failure of the hospital to keep the premises clean and orderly had the potential risk for infection and safety issues due to tripping hazards.

Findings include:

Observation 9/21/15 during initial tour of the hospital revealed the following:

-Emergency room #1 had thick dust (1/4 inch) on the arm of the overhead light that swivels around to examine patients.

-The wall mounted over bed light fixtures at the head of each patient bed had heavy dust/lint build-up on the top horizontal surface, ¼ inch. Also the ceiling vents in the patient bathrooms had a build-up of dust (Patient room # ' s 202, 204, 205, 206, 207, 208, 209, and 210).

-A large metal dietary food cart sitting in the hallway had a heavy dust/lint build-up on top of the cart.

(The food cart is only used during times of high census according to the Assistant Director of Nursing).

-The Cat-Scan room had five floor tiles that were broken causing a fall hazard.

-A community shower room where the medical staff shower daily had a heavy build-up of black mold and mildew on several tiles of the shower and around the base of the shower.

The Assistant Director of Nursing (ID# A) stated at this time that housekeeping should be cleaning/dusting all horizontal surfaces.

Review of forms titled "Environmental Rounds Worksheet" dated 8/31/15 and 7/28/15 stated all areas of the hospital were compliant. No issues were identified.

Based on document review and interview the Governing Body failed to ensure 1 of 3 members of the Professional Staff (ID# D) were reappointed to staff every two years according to the Hospital's Bylaws.

Findings include:

Review of the "Medical Staff Bylaws" dated 9/19/07 stated in section 3.9 "Mechanism For Reappointment: Reappointment to Hospital staff shall be required every two years..."

ID# D is the Medical Director of the Hospital. The physician was last reappointed to medical staff from 1/1/08 to 12/31/09. There have been no further appointments to medical staff.

The Administrator (ID# B) acknowledged 9/23/15 at 1 p.m. that physician ID# D has no other reappointments to the medical staff other than the one dated 1/1/08 to 12/31/09.

Based on observation, interview and document review the critical access hospital failed to #1) ensure sterilization procedures included biological techniques to evaluate the autoclaves effectiveness; and #2) provide separate areas for the decontamination of instruments and the clean area (autoclave/supply room). These deficient practices had the potential for incomplete sterilization of instruments and cross contamination.

Findings include:

-Observation 9/21/15 at 10 a.m. during initial tour of the hospital revealed a steam autoclave in a clean storage room.

Interview with the Infection Control Nurse (ID# E) at this time revealed the only process to check the effectiveness of the autoclave was using sterilizer indicators in each package of instruments to ensure the proper temperature was reached. The Infection Control Nurse stated the hospital does not perform biological indicator testing on the autoclave. The Infection Control nurse stated the hospital sterilizes suturing instruments for the emergency room (hemostats).

Review of the Centers for Disease Control (CDC) position on "Sterilization Procedures" read in part: "Sterilization procedures should be monitored through a combination of mechanical, chemical, and biological techniques designed to evaluate the sterilizing conditions and the procedures effectiveness. Biological Indicators are the most accepted means of monitoring the sterilization process because they directly determine whether the most resistant microorganisms are present rather than determine whether the physical and chemical conditions necessary for sterilization are met."

Interview on 9/22/15 at 9:15 a.m. with the Infection Control Nurse (ID# E) stated that she did some researching and the hospital is supposed to be doing spore testing (biological indicators) on the autoclave weekly.

Review a log titled "Environmental Rounds Worksheet" dated 8/31/15 stated "Disinfection/Sterilization: Chemical and Biological monitors used per policy/Compliant."

Review of the Steam Sterilizer policies revealed no policy for evaluating the autoclave's sterilization process. There were only three policies in the manual dated June 2015 (Wrapping instruments, preparing used items for sterilization, and Caring for your Sterilizer).

-A sink located in the same room as the steam autoclave and clean equipment including: a Hoyer Lift (manual patient lift), bed scale, fluid warmer, suction pumps, IV pump, bladder scanner, and tube feeding pump) was being used as a decontamination area to rinse/clean dirty instruments.

Interview 9/21/15 at 9:20 a.m. with the Infection Control Nurse (ID# E) stated that the dirty instruments are cleaned in the same room with the autoclave and the stored clean equipment.

Based on interview and record review the critical access hospital failed to ensure 3 of 13 closed acute care records reviewed (Patient ID# ' s 5, 6, and 10) had nursing care plans. Failure to have nursing care plans for all patients receiving services had the potential for the hospital to not meet the needs of the patients.

Findings include:

Electronic medical record review revealed the following:

-Patient ID# 5 was admitted to the hospital on 3/10/15 and discharged on 3/13/15. The History and Physical stated the clinical impression " Altered Mental Status, Dehydration, and Urinary Tract Infection. " The record did not have a nursing care plan.

-Patient ID# 6 was admitted to the hospital on 5/13/15 and discharged on 5/16/15. The History and Physical stated the clinical impression " Leukocytosis ( increase in white cells usually indicating an infection), nausea and vomiting, diarrhea, epigastric (upper abdominal) pain, and anorexia (weight loss). " The record did not have a nursing care plan.

-Patient ID# 10 was admitted 3/22/15 and discharged on 3/25/15. The History and Physical stated the clinical impression " Weakness, Fall, Shoulder contusion (bruise). " The record did not have a nursing care plan.

The Assistant Director of Nursing (ID# A) verified 9/23/15 at 1:30 p.m. that she was not able to locate care plans for the above listed patients. The Assistant Director further stated that all patients admitted to the hospital should have a nursing care plan.

Based on interview and electronic medical record review, the critical access hospital failed to have a nursing care plan for 5 of 5 closed swing bed records reviewed (Patient ID# ' s 25, 26, 27, 28, and 29). Failure to have nursing care plans for all swing bed patients receiving services had the potential for the hospital to not meet the patients' needs.

Findings include:

Record review of the following closed swing bed electronic records failed to have a nursing care plan.

-Patient ID# 25 was admitted on 7/7/15 and discharged 7/8/15. The History and Physical clinical impression listed " Acute pancreatitis (inflammation of the pancreas), nausea, anorexia (weight loss), abdominal pain. " The record did not have a care plan.

-Patient ID# 26 was admitted on 5/25/15 and discharged 6/2/15. The History and Physical clinical impression listed " Pneumonia and Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should). " The record did not have a care plan.

-Patient ID# 27 was admitted on 8/3/15 and discharged 8/6/15. The History and Physical clinical impression listed " Congestive Heart Failure and Shortness of Breath. " The record did not have a care plan.

-Patient ID# 28 was admitted on 5/22/15 and discharged on 6/4/15. The History and Physical clinical impression listed " Pneumonia and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest). " The record did not have a care plan.

-Patient ID# 29 was admitted on 6/20/15 and discharged on 6/21/15. The History and Physical clinical impression listed " confusion, urinary tract infection, diabetes, anemia (a condition in which the blood doesn't have enough healthy red blood cells, and weakness. " The record did not have a care plan.

The Assistant Director of Nursing (ID# A) verified 9/23/15 at 1:30 p.m. that she was not able to locate care plans for the above listed swing bed patients. The Assistant Director further stated that all patients admitted to the hospital should have a nursing care plan.