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Based on observation and interview, the CAH (Critical Access Hospital) failed to ensure the implementation of an effective preventative maintenance program by failing to ensure that all patient care equipment was in good repair and/or maintained in a safe operating condition. Findings:

Observations on 6/08/10 between 10:00 a.m. and 11:00 a.m. revealed the following:

Patient Room #3- Rip/Tear measuring 3 inches in length was noted on the vinyl covering of the chair (exposed foam cushioning) in this room making it difficult to ensure disinfection between patient use.
Patient Room #24- Multiple rips/tears were noted on the vinyl covering of the chair (exposed foam cushioning) in this room making it difficult to ensure disinfection between patient use.
Emergency Department Waiting Room- Rips/tears were noted on the vinyl covering of at least 5 chairs in this room. All chairs could not be inspected as there were patients or visitors sitting in many of the chairs.
Emergency Department Room #2- Base of the stretcher in this room was noted to have several sections surface rust. In addition, two areas of flaking paint were noted on the surface of the stretcher making it difficult to ensure disinfection between patient use.
Emergency Department Room #5- Rip/Tear measuring 2 inches in length was noted on the vinyl covering of the mattress pad (exposed foam cushioning) on the stretcher in this room making it difficult to ensure disinfection between patient use.

The Infection Control Officer confirmed the above findings in an interview on 6/08/10 at 2:30 p.m.

Based on observation and interview, the CAH (Critical Access Hospital) failed to ensure the implementation of an effective preventative maintenance program by failing to ensure that all patient care areas were maintained in a manner to ensure the safety and well being of patients. Findings:

Observations on 6/08/10 between 10:00 a.m. and 11:00 a.m. revealed the following:

Patient Room #9- Sections of flaking paint and/or sheetrock were noted on the interior wall in this room.
Patient Room #15- Sections of mold were noted on the ceiling and interior walls in this room. In addition, the room had a musty odor. The mold was removed with a bleach solution.

The Administrator confirmed the above findings in an interview on 6/08/10 at 11:10 a.m.

Based on record review and interview the hospital failed to ensure nursing policies and procedures used in the care of patients had been developed with the advice of professionals, updated according to the current standards of care for nursing care or reflected the procedures performed in the hospital at the present time. Findings:

Review of the Nursing Policy and Procedures, Volume 1 and 2 revealed no documented evidence of the source of the information or the disciplines involved in the development of the policies and procedures. Further the hospital could submit no meeting minutes to verify the policies had been developed with the advice of a physician or a person not a member of the staff.

Review of the Nursing Policy and Procedures, Volume 1 and 2 revealed policies for services no longer provided at the hospital such as Section III Pre-operative and Post-Operative Care last revised 1991; policies with procedures no longer used in the current standards of practice such as orthopedic policies developed in 1975 with no documented evidence of revisions made for the use of pelvic traction, the use of a Stryker frame, cervical traction, skeletal traction and tourniquet rotation dated 01/1975 with no revisions documented; and a cardio-pulmonary resuscitation policy which did not reflect the current standards of ACLS protocol for resuscitation.

In a face to face interview on 06/09/10 at 1:30pm S2 the Director of Nursing (DON) indicated she had hired a new nurse who had recently graduated from nursing school and had assigned her the task of looking into doing the revisions, since she would have up to date information and techniques.

In a face to face interview on 06/09/10 at 1:45pm S1 the Administrator verified the policy and procedure manuals had been signed by the medical director, the president of the board, director of nursing and himself as reviewed; however the policy and procedures had not been read.

Based on record review and interview the hospital failed to ensure a policy had been developed which provide a description of services provided by the hospital. Findings:

Review of the Administrative Manual and Nursing Policy and Procedure Manuals, Volume 1 and 2 revealed no documented evidence a description of the services provided at the hospital had been documented.

In a face to face interview on 06/09/10 at 12:45 S1 the Administrator indicated all policy and procedure manuals need to be revised. S1 verified there was no documentation of the services provided and no list of the contracted services provided or the scope of services offered.

Based on record review and interview, the hospital failed to ensure the implementation of policies/procedures relating to the availability of laboratory services 24 hours a day, 7 days a week to ensure the continuous availability of laboratory services essential to the immediate diagnosis and treatment of patients. Findings:

The hospital approved policies/procedures for laboratory services and the medical staff bylaws were reviewed. This review revealed no documentation to indicate that the medical staff have determined which laboratory services are to be immediately available to meet the emergency laboratory needs of patients who may be currently at the CAH or those patients who may arrive at the CAH in an emergency condition and how the services are to be provided.

The Laboratory Manager was interviewed on 6/08/10 at 1:05 p.m. The Laboratory Manager reported that the hospital has contracted with Laboratory A & Laboratory B for laboratory services. The Laboratory Manager reported that both laboratories provide courier services. The Laboratory Manager reported that laboratory specimens are picked up once daily. When asked about the availability of stat laboratory services, the Laboratory Manager reported that laboratory tests are not usually ordered on a stat basis. The Laboratory Manager reported that in the event of a stat lab, the specimen would be sent to Hospital A or Hospital B for testing. When asked if there was a contract between Hood Memorial Hospital and either Hospital A or Hospital B to indicate that Hospital A or Hospital B was going to provide stat laboratory services to patients hospitalized at Hood Memorial Hospital, the Laboratory Manager reported that there was no contract to indicate that stat services would be available 24 hours a day, 7 days a week.

Review of the hospital approved policies/procedures for laboratory services revealed no documentation to indicate that a policy/procedure was in place relating to a protocol or process to ensure the 24/7 availability of stat laboratory services. Review of the hospital approved policy/procedure titled "General Laboratory Procedure" revealed documentation indicating "Stat tests should be completed within 1 hour. If for some reason this cannot be done, the physician should be notified. After completion, the report should be taken to Nurse's Station, to ER or called to physician immediately. Date, time, tech initials, and initials of person receiving the report are documented". The policy/procedure failed to include a protocol or process for staff to follow in relation to the method of specimen transport to the laboratory or the appropriate laboratory to send the stat specimen to as the laboratory courier service provides a pick up service only once daily.

Review of the contracted services revealed that the hospital has entered into a contract for laboratory services with two different laboratories (Laboratory A & Laboratory B). Review of the contractual agreement with Laboratory A revealed no documentation to indicate that laboratory services were available 24 hours a day, 7 days a week. The contract documents "Laboratory will provide a reference specimen pick up and report delivery service to client on a daily basis Monday through Friday of each week, except on holidays. For the purpose of this Agreement, holidays shall include New Year's Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day, and Christmas Day". There was no documentation in this contract to indicate that stat laboratory services were available 24 hours a day, 7 days a week. Review of the contractual agreement with Laboratory B revealed no documentation to indicate that stat laboratory services were available 24 hours a day, 7 days a week.

Based on record review and interview the hospital failed to monitor contracted services to ensure quality of the services provided. Findings:

Review of the Quality Assurance/Performance Improvement Department indicators submitted as the ones presently in use by the hospital revealed no inclusion of the contracted services provided to the hospital.

The hospital could submit no documented evidence that contracts had been monitored to ensure the quality of their performance in providing service or care to the patients at the hospital.

In a face to face interview on 0-6/09/10 at 12:45pm S1 the Administrator verified at the present time the hospital was not monitoring contract other than for renewal purposes.