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Based on observation, review of administrative policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to maintain a the building safe from fire when it failed to develop and implement a system to assure the provision of electricity for the CAH and critical care equipment in the event of the loss of the usual electricity source. See the Life Safety Code Survey dated 8/2/13 and C-0231.

The cumulative effect of these systemic problems resulted in the CAH's inability to assure the provision of care in a safe environment. The lack of an effective program to maintain the facility's equipment resulted in an immediate jeopardy when the life safety code surveyor identified that the facility failed to maintain and test the emergency generator power as required on 8/1/13.

The Critical Access Hospital (CAH) reported a census of three acute patients, five swing bed patients, and four Behavior Health Unit (BHU) patients. Based on observation, staff interview and document review, the CAH failed to ensure the CAH's premises are clean and orderly.

Findings include:

- Observation of the purchasing department on 7/30/13 at 9:40am revealed multiple puddles of water on the floor by an air handling unit in the department. A cart with patient care equipment sat in a puddle. Patients' new water pitchers sat on a shelf uncovered. A film of dust was present on the pitchers, boxes of sutures and the outer wrap of sterile sets.

- Infection Prevention officer C, interviewed on 7/31/13 at 11:00am acknowledged the water on the floor and dust on the patient care equipment rendered the items unclean.

- Administrator A, interviewed on 7/31/13 at 4:30pm, acknowledged the CAH lacked a policy directing staff to report water and dust in patient care storage areas.

The Critical Access Hospital (CAH) reported a census of three acute patients, five swing bed patients, and four Behavior Health Unit (BHU) patients. Based on document review and staff interview the CAH failed to develop and implement a system to assure the provision of emergency electricity for the CAH and critical patient care equipment in the event of the loss of the CAH's usual electricity source. This placed patients at risk to their health and safety, especially if loss of electricity would occur during a surgical procedure or delivery of a baby.

Findings include:

- In consultation with the Life Safety Code (LSC) surveyor, the State Office and the Centers for Medicare and Medicaid services, the CAH was notified of the findings of Immediate Jeopardy by the LSC surveyor on 8/1/13 at 11:55am.

- For additional information see the Life Safety Code survey results dated 8/2/13.

- Observation of Patient #11 on 7/30/13 at 7:30am revealed licensed nurse J prepared to perform a finger stick blood sugar check. Staff J placed the glucometer on patient #11's bed and performed the test. Staff J proceeded to patient #13's side and performed a glucometer check. Staff J proceeded to patient #14's room and placed the glucometer on the patient's chair. Staff J obtained the glucometer check and returned the glucometer to the medication room. Staff J failed to clean the glucometer after it contacted the potentially contaminated surfaces and replaced it in the medication room.

- Physical therapist K, interviewed on 7/30/13 at 10:45am, revealed the physical therapy department is cleaned daily by housekeeping and the therapy staff use "SaniZene" to disinfect surfaces. Observation of the disinfectant containers revealed a unlabeled spray bottle and a partial gallon jug of 'SaniZene". The solution in the jug was thick and gold colored.

Infection control officer C, interviewed on 7/31/13 at 11:00am revealed "SaniZene" is not an approved disinfectant for CAH use. Staff C acknowledged the CAH lacked manufacterer's instructions for the use of the disinfectant.








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The Critical Access Hospital (CAH) reported a census of three acute patients, five swing bed patients, and four Behavior Health Unit (BHU) patients. The CAH's data base worksheet completed by hospital staff reported the CAH staffed 25 acute and swing beds, ten BHU patients, and provided the following services: x-ray, emergency department, laboratory, inpatient and outpatient surgery, obstetrical/newborn services, therapy services, psychiatric services and outpatient treatments. Based on observation, document review and staff interview, the CAH failed to develop a system to identify and control infections or staff practices which could contribute to healthcare acquired infections of patients and personnel. Observations included one surgical procedure, staff cleaning a discharged patient room, staff performing three glucometer tests, staff administering medications/blood products to two patients. The CAH's inability to identify failures with infection control practices, failure to follow cleaning policy and procedures, and failure to follow acceptable professional standards of practice created the potential for healthcare acquired infections of patients and personnel.

Findings include:

- The CAH's policy titled "Infection Control Program", reviewed on 8/1/13 at 10:30am directed, "...The Infection Control Nurse is responsible for all surveillance and data collection working with the Departments' Managers in making needed revisions..."

- The CAH's policy titled Hand Hygiene, reviewed on 7/31/13 at 10:30pm, directed, hand hygiene is to be performed "...before and after patient contact..."
- Nursing staff E observed on 7/29/13/13 at 1:00pm entered patient #37's room to increase the intravenous (IV) blood infusion rate. Staff E failed to perform hand hygiene when entering patient #37's room.

- The CAH's policy for items to be cleaned after use reviewed on 8/1/13 at 11:00am, directed "...These items are to be cleaned after use: Remove visible soiling; then wipe down with current approved hospital disinfectant ...Top of the Medication Cart, Precision G (a glucometer) ..."

- Nursing staff G observed on 7/30/13 at 9:00am entered patient #17's room to administer oral medications. Staff G failed to perform hand hygiene when entering patient #17's room. Staff G removed a medication bin from the medication cart, placed the bin on patient #17's bedside table without a protective barrier, administered medications to patient #17, and replaced the bin in the medication cart without disinfection of the bin.

Infection Control Nurse staff C interviewed on 8/1/13 at 11:00am acknowledged the CAH failed to have a policy and procedure developed on cleaning of medication bins after uses in a patient room.

The failure of two staff members to follow hospital policy and acceptable standards of practice for hand hygiene and two staff members that failed to clean equipment between patients created the potential for the spread of healthcare acquired infections between patients in the hospital.

- The CAH's policy "Patient Room Dismissal-Cleaning Procedures" reviewed on 8/1/13 at 10:30am directed, "...Damp mop floor using a mop wrung out in germicidal solution ..."

- The manufacturer's information sheet for "3M Neutral Cleaner" reviewed on 8/1/13 at 11:45am revealed the solution is a ready-to-use neutral cleaner designed to clean washable surfaces. Information for "3M Neutral Cleaner" failed to indicate the solution as a germicidal disinfectant.

- Housekeeping staff F observed on 7/30/13 between 12:50pm to 2:10pm cleaned room 115 a discharged patient room. Staff F obtained a mop and mopped the floor with "3M Neutral Cleaner". Staff F failed to follow the CAH's policy to apply a germicidal to the floor to disinfect the floor between patients.

Housekeeping staff F interviewed on 7/30/13 at 2:10pm verified they used "3M Neutral Cleaner" to clean the floor in room 115.

Infection Control officer C, interviewed on 8/1/13 at 11:45am, acknowledged "3M Neutral Cleaner" is not to be used when preparing a room between patients.

- "The Association of periOperative Registered Nurses (AORN) periOperative Standards & Recommended Practices" 2011 edition manual "Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting" review on 8/1/13 at 10:00am directed" ...Protective barriers must be used to reduce the risk of skin and mucous membrane exposure to potentially infectious materials ...Health care workers must wear masks to protect the mucous membranes of the nose and mouth during procedures and activities that generate splashes, splatters, sprays, of aerosols of blood or other potentially infectious materials ...Health care workers must wear protective eye wear when splatter is anticipated ...Health care workers must wear a face shield if a splash is anticipated..."

- Patient #38's medical record revealed an outpatient admission date of 7/31/13 for a colonoscopy (a test to examine the large intestine using a small camera on a flexible tube passed through the anus).
Observation of the colonoscopy on 7/31/13 between 10:17am and 11:10am revealed staff I performing the procedure. During the procedure staff I failed to wear a mask, protective eyewear, or facial shielding during a procedure with a potential to generate splashes of body fluids, secretions and excretions.

Operating Room Administrative Staff H interviewed on 8/1/13 at 10:00am indicated the surgery department uses "The Association of periOperative Registered Nurses (AORN) periOperative Standards & Recommended Practices" as their standard of practices. Staff H acknowledged staff should wear masks and eye protection during procedures with the potential to generate splashes of blood, body fluids, secretions, and excretions.

- Observation on 7/31/13 at 11:42am during environmental tour of the Surgical Suite revealed a soiled utility room with one red biohazard plastic bag with surgical waste, one clear plastic bag with surgical linens and one clear plastic bag with soiled surgical trash resting directly on the floor.

Operating Room Administrative Staff H interviewed on 7/31/13 at 11:42am acknowledged the trash bags have the potential for contamination due to leakage.