HospitalInspections.org

The Critical Access Hospital reported a census of two acute patients, and thirteen swing bed patients. The CAH ' s data base worksheet, completed by the hospital ' s staff reported the CAH staffed 25 acute and swing beds and provided the following services: x-ray, emergency department, laboratory, inpatient and outpatient surgery and therapy services. Based on observation and staff interview the CAH (Critical Access Hospital) failed to develop and maintain a system to monitor and remove outdated (beyond the manufactures recommended use date) inventory of emergency supplies which are readily available for treating patients in one of one nursing supply room and one of two crash carts.
Findings include:
- Observation on 2/3/14 at 10:40am revealed the following outdated supplies in the nursing supply room:
1. Two disposable skin staplers which expired on 11/2013.
2. Twenty-eight Tegaderm skin dressings 9 which expired on /2013.
3. Twenty-two Tegaderm skin dressing which expired on of 7/2012.
4. One Tegaderm skin dressing which expired on 9/2012.
5. Six Tegaderm skin dressings which expired on 10/2011.
6. Forty 20 gauge Huber needles (used to access under the skin IV port) which expired on 11/2013.
7. One 20 gauge Huber needle which expired on 6/2010.
8. Twelve 20 gauge Huber needles which expired on 12/2013.
9. One 19 gauge Huber needle which expired on 9/2011.
10. Two 19 gauge Huber needles which expired on 2/2012.
11. Seven 20 gauge Huber needles which expired on 5/2013.
12. Seventy-one Statlock stabilization devices (extensions for IV sites) which expired on 12/2013.
13. Twenty-two Statlock stabilization devices which expired on 4/2013.
Nursing staff C interviewed on 2/3/14 at 11:10am in the nursing supply room acknowledged there were expired/outdated supplies available for staff to use with patients.
- A crash cart located at the nursing station on 2/3/14 at 11:30am contained the following outdated supplies:
1. One 22 gauge Insyte IV catheter (for intravenous access) which expired on 6/2013.
2. Three 10 milliliter vials of normal saline which expired on 10/2012.
3. One 18 gauge Safety needle which expired on 12/2013.
Nursing Staff C interviewed on 2/3/14 at 11:35am acknowledged the hospital had expired/outdated supplies in the crash cart by the nursing station which staff could use on patients.

The Critical Access Hospital (CAH) reported a census of two acute patients, and thirteen swing bed patients. The CAH's data base worksheet completed by hospital staff reported the CAH staffed 25 acute and swing beds. Based on observation, document review and staff interview, the CAH failed to plan and maintain an emergency water supply for all patients and staff in the event of a non-medical emergency.

Findings include:

- Recommendation from the FEMA (Federal Emergency Management Agency) website reviewed on 2/6/14 at 3:20pm direct, " ...Store at least one gallon, per person, per day ... "

-Maintenance staff F interviewed on 2/4/14 at between 9:00am to 10:25am lacked knowledge of the amount of emergency water at the CAH and thought there were 24 bottles (12 ounce) in the storage shed. Staff F acknowledged the hospital lacked a supply of drinking water in the event of a disruption of the usual water supply.

Staff F interviewed on 2/6/14 at 9:00am confirmed the hospital lacked a plan and supplies for drinking water in the event of a disruption in the usual water service.

- Observation of the hospital storage shed on 2/6/14 at 1:00pm revealed 48 (12-ounce) bottles of drinking water.

The Critical Access Hospital (CAH) reported a census of two acute patients, and thirteen swing bed patients. The CAH's data base worksheet completed by hospital staff reported the CAH staffed 25 acute and swing beds, and provided the following services: x-ray, emergency department, laboratory, inpatient and outpatient surgery, therapy services. Based on observation, document review and staff interview, the CAH failed to develop a system to identify and control infections for staff practices for one of one observation of staff cleaning of a discharged patient room, two of four observations of staff administering medications to two patients, one of two observations of staff initiating an intravenous (IV) site, and one of two observed janitorial closets. The CAH ' s failure 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.

Findings include:

- The CAH's policy "Infection Prevention and Control Plan", reviewed on 2/5/14 at 3:45pm directed, "...The goal of the infection prevention program are to have an effective surveillance program to: A. Decrease the risk of infection to patients and personnel..."

Staff H interviewed on 2/5/14 at 1:40pm verified they were responsible for the management of the infection control program. The CAH's infection control committee reviews policies and procedures and approves hospital wide cleaning products. Staff H provided a quarterly hand hygiene study for the third quarter of 2012 with a staff compliance of 54.84%. Staff H acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control for the year of 2013. Staff E acknowledged they failed to develop and implement a surveillance program for staff infection control practices.

- Observations during the survey process revealed the following breaches in infection control practices for hand hygiene, disinfectant wet time per manufacturer's recommendation, and disposal of biohazard trash.

- Nursing staff D observed on 2/3/14 at 1:30pm entered patient # 33 ' s room to start an IV. Nursing staff D explained procedure to patient, washed hands, applied gloves and tore off left index finger on gloves exposing skin and started the IV (intravenous) site.
Infection Control Nurse Staff H interviewed on 2/6/14 at 1:30pm indicated staff use Lippincott Procedures for reference for IV catheter insertion. Lippincott IV catheter insertion procedure reviewed on 2/6/14 at 1:30pm directed " put on gloves " in preparation for IV catheter insertion.
- The CAH's policy " Hand washing " , reviewed on 2/5/14 at 4:00pm, directed, " ...personnel shall wash their hands to prevent the spread of infection ...before applying and after removing gloves, between handling of individual patients..."
- Nursing staff D observed on 2/3/14 at 1:52pm entered patient #32 ' s room to administer medication. Staff D failed to perform hand hygiene when entering or exiting patient #32 ' s room.
- The manufacturer's information sheet for "Virex II 256" reviewed on 2/5/14 at 3:45pm directed when used as a disinfectant, " ...all surfaces must remain wet for 10 minutes ..."

- The manufacturer's information sheet for "Crew NA " toilet disinfectant cleaner reviewed on 2/5/14 at 3:45pm directed for disinfection "...remove water from toilet bowl ...apply a 1 ounce per gallon solution to exposed surfaces...allow to stand for 10 minutes and flush ..."

- Housekeeping staff E observed on 2/3/14 between 2:35pm to 3:15pm cleaning room 2, a discharged patient room revealed the following breaches in infection control practices regarding hand hygiene and disinfectant wet time per manufacturer's recommendation. For example:

Staff E, wearing gloves applied " Virex II 256 " disinfection cleaner to the bedside table, radiator, chair, and trash can. The surfaces remained wet for one to four minutes not the required ten minutes for disinfection.

Staff E returned to the cleaning cart for supplies and failed to remove their gloves, perform hand hygiene and apply clean gloves.

Staff E returned to room 2 to clean the bathroom and found linens in the shower stall. Staff E left the room with the soiled linens and carried them to the soiled utility room. Staff E failed to contain the soiled linen in an enclosed container.

Staff E, returned to room 2, applied " Virex II 256 " disinfectant cleaner to the walls, sink and faucet. The surfaces remained wet between one to three minutes not the required 10 minutes for total disinfection. Staff E then applied " Virex II 256 " to the shower stall and immediately sprayed the shower stall with water.

Staff E, using " Crew NA " toilet bowl cleaner, poured an unmeasured amount in the toilet bowl without removing the water from the bowl as directed by the manufacturer.

Staff E, interviewed on 2/3/14 at 5:00pm, acknowledged the cleaned surfaces failed to remain wet the required 10 minutes and they failed to remove the water from the toilet bowl prior to cleaning the toilet bowl as directed by the manufacturer.
- Observation of a janitorial closet in the Radiology hallway on 2/4/14 at 9:10am revealed a red biohazard plastic bag resting directly on the floor.
Maintenance Staff F and Nursing staff B interviewed on 2/4/14 at 9:10am acknowledged the red biohazard bag had the potential for contamination due to leakage and verified the bags should not be on the floor.

- Nursing staff G observed on 2/4/14 at 10:55am entered patient #14's room to administer a medication. Staff G failed to perform hand hygiene when entering or exiting patient #14's room.

Nursing staff G on 2/4/14 at 11:05 acknowledged they failed to perform hand hygiene when they entered and exited patient #14 ' s room.