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Based on interview and review of the facility's Temperature and Humidity Log and the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide the required temperature in three of three (Operating Room (OR) 1, OR 2, Gastrointestinal (GI) Room) surgical areas. The failed practice had the likelihood to affect all patients undergoing procedures in these spaces in that a sterile environment was not ensured and an elevated risk of infection was present. Findings follow:
A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 showed operating rooms and endoscopy rooms shall be provided with a dry bulb temperature of 68-73 degrees Fahrenheit.
B. Review on 1/25/22 at 9:00 AM of the facility's Temperature and Humidity Log Policy showed the facility required the temperature of the Operating Rooms to be kept below 68 degrees Fahrenheit at all times.
C. Review on 1/25/22 at 9:00 AM of the facility's Temperature and Humidity Log for the 12 months prior to the survey (January 2021 - December 2021) showed OR 1 was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 202 days of the 202 days recorded.
D. Review on 1/25/22 at 09:00 AM of the facility's Temperature and Humidity Log for the 12 months prior to the survey (January 2021 - December 2021) showed OR 2 was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 202 days of the 202 days recorded.
E. Review on 1/25/22 at 09:00 AM of the facility's Temperature and Humidity Log for the 12 months prior to the survey (January 2021 - December 2021) showed the GI Room was kept at a temperature outside of the required range of 68-73 degrees Fahrenheit for 200 days of the 202 days recorded.
F. The above findings were verified with the Director of Plant Maintenance on 1/25/22 at 1:00 PM.

Based on observation and review of the Rules for Critical Access Hospitals in Arkansas 2021 and National Fire Protection Association (NFPA) 99 2012 Edition, it was determined the facility failed to mark empty medical gas cylinders and segregate them from full cylinders in accordance with NFPA 99 standards. The failed practice had the likelihood to affect all patients relying on portable oxygen in that in the event of an emergency the staff would not be able to determine if an available cylinder was empty or not. Findings follow:

A. Review of the Rules for Critical Access Hospitals in Arkansas 2021 showed medical gas storage shall be provided in accordance with NFPA 99.
B. Review of NFPA 99 2012 Edition: 11.6.5.2 showed empty medical gas cylinders shall be segregated from full cylinders stored in the same enclosure.
C. Review of NFPA 99 2012 Edition: 11.6.5.3 showed empty medical gas cylinders shall be marked to avoid confusion if a full cylinder is needed in a rapid manner.
D. Observation of the Medical Gas Central Supply room on 1/25/22 at 2:35 PM showed empty and full medical gas cylinders stored together without segregation, and empty cylinders had no markings to indicate they were empty. This finding was verified with the Director of Plant Maintenance at the time of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to use multiple-receptacle power cords in accordance with NFPA 99 standards in two of two patient care areas (Operating Room 1, Operating Room 2) in that there was no measure in place to prevent additional devices from being plugged in to the power cords, and there was no measure in place to ensure the devices powered by the cords did not exceed 75% of each cord's rated ampacity. The failed practices had the likelihood to affect all patients receiving care in the vicinity of the power cords in that there were no processes in place to ensure the cords would not exceed their ampacity and cause a fire or electrical shock. Findings follow:

A. Review of NFPA 99 2012 Edition: 10.2.3.6 showed flexible power cords with two or more receptacles shall be permitted to be used provided they are permanently attached to the assembly they are powering, the sum of all appliances connected to the outlets does not exceed 75% of the power cord's ampacity, the electrical and mechanical integrity of the cord are regularly verified and documented, and means are employed to ensure additional devices or nonmedical equipment cannot be connected to the power cords after leakage currents have been verified as safe.
B. Observation on 1/25/22 at 2:05 PM of Operating Room 1 showed a portable monitor was being powered by a multiple-receptacle power cord with 8 receptacles which was plugged into the wall. There was no measure in place to prevent additional devices from being plugged in to the power cord.
C. Observation on 1/25/22 at 2:10 PM of Operating Room 2 showed a portable monitor was being powered by a multiple-receptacle power cord with 10 receptacles which was plugged in to the wall. There was no measure in place to prevent additional devices from being plugged in to the power cord.
D. In an interview with the Director of Maintenance on 1/25/22 at 2:25 PM the above findings in B and C were verified. It was also verified in this interview that the facility had no process in place for ensuring that the sum of the ampacity of all appliances connected to the multiple-receptacle power cord does not exceed 75% of the power cord's ampacity in Operating Room 1 or Operating Room 2.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 99 Health Care Facilities Code 2012 Edition and NFPA 70 National Electric Code 2011 Edition, it was determined that the facility failed to maintain a working clearance in front of one of one electrical panel in the CT Scan room as required by NFPA 70. The failed practice had the potential to affect all patients and staff in the CT Scan room because rapid access to the panels could not be gained in the event of an emergency and could prevent an electrical or fire hazard from being addressed quickly. Findings follow:

A. Review of NPFA 99 2012 Edition: 15.5.1.2 showed that electrical equipment shall be in accordance with NFPA 70.
B. Review of NFPA 70 2011 Edition: 110.26 showed that access and working space of at least 36 inches (3 feet) shall be maintained for electrical equipment operating at 600 volts, nominal, or less to ground and working spaces shall not be used for storage.
C. While touring the CT Scan room on 1/27/22 at 9:45 AM, it was observed that a plastic cart holding medical supplies was stored directly in front of the electrical panel at the rear of the room. This finding was verified with the Director of Plant Maintenance at the time of observation.

Based on observation, review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas, and interview, it was determined the facility failed to ensure all patient care equipment was maintained in safe operating condition in that one of one medical gas area alarm panel in the Surgical Corridor and one of one Airborne Infection Isolation Patient Room (AII Room) in the Medical-Surgical department were not maintained in working condition. The failure to maintain the medical gas area alarm had the potential to impact all patients receiving surgical procedures relying on medical gases in that if there was any adverse event with the medical gas system, such as a dangerous rise or drop of pressure, there was no alarm in place to notify staff in the operating rooms to correct the issue or protect the patient from harm. The failure to maintain the AII Room had the potential to affect all patients and staff in the Medical-Surgical department in that there was no inward airflow in the AII Room to ensure that a patient in the AII Room carrying an infectious airborne disease would not be able to transmit the disease to nearby patients and staff in the Medical-Surgical unit. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021: Table 4 showed Airborne Infection Isolation rooms shall have air movement flowing inward from the adjacent area.
B. Observation on 1/26/22 at 9:40 AM of the Airborne Infection Isolation Patient Room, room #21, in the Medical-Surgical unit showed that the patient room was not negatively pressurized relative to the adjacent space to prevent air from flowing outward from the AII Room into the corridor as required by the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021. This finding was verified with the Director of Plan Maintenance at the time of observation.
C. Observation of the Surgical Corridor leading to Operating Room 1, Operating Room 2, and the Gastrointestinal Procedure Room showed a medical gas area alarm panel was present on the wall near the door to Operating Room 1, and the alarm panel was not illuminated or functioning. This finding was verified with the Director of Plan Maintenance at the time of observation.

Based on observation, interview and review of National Fire Protection Association (NFPA) 101 2012 Edition Life Safety Code standards, it was determined the facility failed to maintain four (Medical Gas Central Supply, Medical-Surgical Unit, Emergency Department, Administration Corridor) of five fire-rated barriers in accordance with the requirements of NFPA 101 2012 Edition in that the barriers had penetrations which were not sealed with fire-proof sealant to restrict the transfer of smoke. The risk of fire or smoke spreading had the likelihood to affect all patients, visitors, and staff in the facility. Findings follow:

A. Review of NFPA 101 2012 edition: 8.3.5.1 showed penetrations for cables, conduits, pipes, and wires that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.
B. Observation on 1/25/22 at 2:35 PM of the fire-rated barrier surrounding the Medical Gas Central Supply room showed two penetrating cables that were not sealed by a firestop system or device to prevent the transfer of fire and smoke.
C. Observation on 1/27/22 at 10:15 AM of the fire-rated barrier in the Administration Corridor near the exit hallway doorway showed two tubes with wires in them penetrating the barrier which were not sealed with fire-proof sealant to restrict the transfer of smoke.
D. Observation on 1/27/22 at 10:20 AM of the fire-rated barrier at the Emergency Department entrance showed a 1-inch-diameter tube with a yellow wire inside penetrating the barrier which was not sealed with fire-proof sealant to restrict the transfer of smoke.
E. Observation on 1/27/22 at 10:25 AM of the fire-rated barrier in the Medical-Surgical Unit near the nurse station showed a 2-inch-diameter hole in the barrier which was not sealed with fire-proof sealant to restrict the transfer of smoke.
F. The above findings in B, C, D, and E were verified with the Director of Plant Maintenance at the times of observation.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition, the facility failed to maintain six of six (Surgical Soiled Room, Surgical Equipment Room, Gastrointestinal (GI) Room, Operating Room (OR) 1, OR 2, Medical Records) fire-rated door assemblies as required by NFPA 101 2012 Edition in that all six of the fire-rated door assemblies were not arranged for automatically closing and latching when released. The failed practice had the likelihood for the fire-rated doors to be left open in the event of a fire, allowing smoke and fire to rapidly transfer into the adjacent spaces. The failed practice had the likelihood to affect all patients, staff, and visitors in the facility. Findings were as follows:

A. Review of NFPA 101 2012 Edition: 7.2.1.8.2 showed any door leaf required to be kept closed shall only be held open by a device which automatically releases the door leaf upon operation of a smoke detector and upon loss of power to the device. Review of NFPA 101 2012 Edition: 8.3.3.1 showed all openings required to have a fire protection rating shall be protected by fire door assemblies and accompanying hardware in accordance with NFPA 80.
B. Review of NFPA 80 2010 Edition: 5.1.3.2 showed fire-rated doors shall be kept closed and latched or arranged for automatic closing. Review of NFPA 80 2010 Edition: 6.1.4.2.1 showed self-closing doors shall be equipped with a closing device to cause the door to close and latch each time the door is opened.
C. Observation of the Surgical Suite on 1/25/22 from 2:00 PM to 2:20 PM showed the entrances to OR 1, OR 2, GI Room, Surgical Soil Room, and Surgical Equipment Room were comprised of doorways consisting of fire-rated door assemblies which had kick-down stoppers installed on the door leaves of each fire-rated door assembly. These stoppers prevented the door leaves from closing when pushed into place and were not capable of automatically releasing upon activation of a smoke detector or loss of power.
D. Observation of the Medical Records room on 1/25/22 at 1:25 PM showed the entrance was comprised of a doorway consisting of a fire-rated door assembly. Further observation showed the door assembly did not have a closing device installed to ensure automatic closing and latching, and the door leaf did not close when opened and released.
E. The above findings in C and D were verified with the Director of Plant Maintenance at the times of observation.

Based on review of Medical Staff Bylaws, review of credential files and interview, it was determined the Governing Body failed to ensure there were current completed Clinical Privileges forms in the applicants' files prior to being approved to practice for one (Certified Registered Nurse Anesthetist (CRNA) #1) of four (CRNAs#1-4) and one (Surgeon #3) of four (Surgeons #1-4). By not having a process that ensures the Facility maintains the necessary documents, the Governing Body could not assure the patients were receiving treatments from qualified CRNAs and Surgeons. The failed practice had the likelihood the affect all the patients that received care in Surgical Services. Findings follow:

A. Review of the Medical Staff Bylaws showed each applicant must include a completed form specifically delineating the Clinical Privileges desired by the applicant.
B. Review of Credential files on 1/25/22 showed CRNA #1 and Surgeon #3 did not have a completed form specifically delineating the Clinical Privileges desired by the applicant. CRNA #1 had received Governing Body approval through 8/1/23. Surgeon #3 had received Governing Body approval through 12/1/22.
C. During an interview on 1/25/22 at 10:58 a.m., the Administrative Assistant verified there was no evidence of a completed form specifically delineating the Clinical Privileges desired by the applicant.

Based on review of policy, review of Medication Error Incident Reports, review of clinical records and interview, it was determined the facility failed to assure evidence of medication errors were recorded along with notification to the practitioner in 2 (#9 and #13) of 3 (#9, #13 and #23) patients who received the wrong medication. The failed practice did not assure the physician was aware of the medication error so that treatment, if any, could be altered. The failed practice had the likelihood to affect any patient with a medication error. The findings follow:

A. Record review of the facility's policy titled, "Medication Events," revised 12/02/08, showed that when a medication error occurs, the medication that was given in error must be documented in the patient medical record, along with notification of the physician and any resultant orders due to the error.
B. Review of Medication Error Incident Reports for the previous 12 months (January through December 2021) showed 3 errors that involved a patient receiving the wrong medication.
C. Review of the 3 Medication Errors in the clinical records showed there was no evidence of documentation of the medication error and notification to the physician for 2 (#9 and #13) of 3 (#9, #13 & #23) patients who received the wrong medication (Regen-Cov and Remdisivir).
D. During an interview on 01/26/22 at 1:54 p.m., the Medical/Surgical Manager verified there was no evidence in the patients' clinical records of the medication that was given in error or notification of the physician and any resultant orders due to the error.

Based on policy and procedure review, review of manufacturer's instructions for use, observation, and interview, it was determined the facility failed to ensure personal radiation dosimeters were stored with controls, in a radiation free environment, and with dosimeters of the same type and wear date when not in use. The failed practice did not assure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected all employees required to wear a dosimeter. Findings follow:

A. Review of Radiology Department Policy and Procedure Manual showed no policy regarding the storage of dosimeters.
B. Review of Landauer Control Dosimeters Instructions for use showed, "Do not use the control dosimeter for any other purpose! Store control dosimeters away from radiation with dosimeters of the same type and wear date when not in use (do not store dosimeters near a radioactive source or in an X-ray room)."
C. During a tour of the Radiology Department on 1/27/22 at 2:32 PM there was no designated storage area observed for employee dosimeters when not in use.
D. In an interview with the Radiology Manager on 1/27/22 at 2:32 PM, he stated there was no policy and procedure for storing dosimeters and that employees often just carried them in their pockets or may take them home when not in use.

Based on policy and procedure review, record review, and interviews, the facility failed to obtain properly executed consent for treatment forms. Failure to provide patients with consent for treatment on admission did not allow patients to make informed decisions regarding their care. Findings follow:

A. Review of policy procedure titled, "Informed Consents," dated 02/13/20, and obtained from the Director of Nurses on 02/02/22 showed: A general consent for treatment of the patient and/or a person of legally empowered to give consent would be obtained at the time of admission for all types /classifications of patients.
B. Review of clinical records from the Emergency Department (Patients #9-13) showed no signed consent for treatment for 4 (Patient #9, #10, #12, and #13) of 5 clinical records. Further review showed that the same 4 charts were COVID-positive patients.
C. During an interview on 01/27/22 at 2:10 PM, Medical Surgical Nurse Manager verified findings in A and B and stated that all patients presented to the Emergency Department with COVID symptoms did not sign informed consent forms.

Based on observation, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, it was determined the facility failed to mitigate risks of healthcare related infections by not identifying unsafe injection practices by using the same 500 ml (milliliter) normal saline single use bag dated 01/16/22 as a flush for multiple patients undergoing CT (Computed Tomography) procedures requiring contrast. By not identifying the risk this practice, the facility could not assure the control of the spread of infection (such as human immunodeficiency virus (HIV) and Hepatitis) and assure patient safety. This failed practice had the potential to affect 34 of 34 (#29 - #62) patients receiving a CT with contrast from 01/16/22 to 01/27/22 and had the likelihood to affect all patients receiving CT with contrast procedures in the facility. See C-1208.

Based on review of Association of Peri-Operative Registered Nurses (AORN) Guidelines 2012-2021, observation, and interview, it was determined the CRNA's failed to provide a sanitary environment for the storage of 17 of 17 laryngoscope blades in 2 of 2 Anesthesia Carts (#1 and #2) in the Surgical Services Area as the blades were observed in the drawer opened with no sterile packaging observed. The failed practice did not assure patients would be protected from infection and had the likelihood to expose all patients treated in the Surgical Services area to potential sources of infection. Findings follow:

A. Review of AORN Guidelines 12. Laryngoscope Blades and Handles showed, 12.4
"Package and store reusable laryngoscope blades and handles that have been high-level disinfected or sterilized in a manner that prevents contamination and identifies them as ready for use."
B. During a tour of Surgical Services on 01/25/22 at 1:55 PM, there were 17 blades observed with no packaging in Anesthesia Cart #1 and 4 blades observed with no packaging in Anesthesia Cart #2.
C. During an interview with the Operating Room Manager on 01/25/22 at 2:31 PM, they verified the findings at A. and B.

Based on observation, review of Occupational Safety and Health Administration's (OSHA's) regulations and interview, it was determined the facility failed to mitigate the risk of contamination in Surgical Services in that three of three (Operating #1, Operating #2 and the GI Procedure) rooms had 8-gallon Sharps containers that were not properly maintained. By not maintaining the Sharps containers properly, the facility was taking a risk of contamination to the room and/ or healthcare associated infections, which potentially created an unsafe work environment. The findings were:

A. Review of (OSHA's) regulation 29 CFR 1910.1030(d)(4)(iii)(A)(2)(ii) showed a requirement that facilities that use Sharps containers for contaminated waste must ensure they are maintained in an upright position.
B. During a tour of the facility on 1/25/22 from 1:15 PM. to 2:31 PM, observation showed the following:
1) Operating Room #1 had two 8 gallon Sharps containers that were not secured by any means and could be tipped over accidentally;
2) Operating Room #2 had two 8 gallon Sharps containers that were not secured by any means and could be tipped over accidentally; and
3) Procedure Room had one 8 gallon Sharps container that was not secured by any means and could be tipped over accidentally.
C. During an interview on 1/25/22 at 2:31 p.m., the Operating Room Manager verified the findings at B.


40282

Based on observation, review of Centers for Disease Control and Prevention (CDC) guidelines, and interview, it was determined the Facility failed to mitigate risks of healthcare related infections by not identifying unsafe injection practices by using the same 500 ml normal saline single use bag dated 01/16/22 as a flush for multiple patients undergoing CT (Computed Tomography) procedures requiring contrast. By not identifying the risk this practice carries, the facility could not assure the control of the spread of infection (such as human immunodeficiency virus (HIV) and Hepatitis) and assure patient safety. This failed practice had the potential to affect 34 of 34 (#29 - #62) patients receiving a CT with contrast from 01/16/22 to 01/27/22 and had the likelihood to affect all patients receiving CT with contrast procedures in the facility. Findings follow:

A. During tour of the Radiology Department in the CT room on 01/27/22 at 2:45 PM, showed one of one 500 ml bag of 0.9 Sodium Chloride dated 01/16/22 hanging on a pole by a contrast machine with approximately 400 ml of fluid remaining in the bag.
B. Review of CDC guidelines titled "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)," Safe Injetion Practices IV.H showed "Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use."
C. During interview with the Radiology Manager on 01/27/22 at 2:50 PM, he stated the 0.9 Sodium Chloride bag attaches to the machine and a syringe with contrast also attaches to the machine. The patient also has an intravenous line going into the syringe with contrast. He stated the 0.9 bag of Sodium Chloride was used as a flush.
D. During an interview with the Infection Control Nurse on 11/27/22 at 1:00 PM she stated the Facility followed the CDC guidelines for infection control practices.
E. Findings in A and C were verified by the Radiology Manager at 2:55 PM on 01/27/22.


Based on observation, policy and procedure review, and interview, the hospital failed to follow their policies and procedures and failed to assure techniques and measures were implemented to eliminate possible contamination of 3 of 3 pre-packaged sterile anesthesia supplies. Failure to assure proper storage and handling of sterile pre-packaged anesthesia supplies did not ensure supplies were kept sterile for patient use. The failed practice had the potential to affect surgical patients receiving anesthesia. Findings follow:

A. Review of undated policy and procedure titled, "Department of Infection Control," showed that anesthetists shall ensure the cleanliness or sterility as appropriate of all materials and equipment to be used in the administration of anesthesia.
B. During tour of Operating Room Number One in Surgical Services on 01/25/22 at 1:35 PM showed 3 of 3 opened single use Bougie devices stored in one open bougie package taped to the side of the anesthesia cart.
C. During an interview on 01/25/22 at 1:38 PM, Director of Surgical Services stated that the anesthesia provider removes the single-use Bougie devices from original packaging and places multiple Bougie devices in one open package on the side of the anesthesia cart for emergency use during intubation.
D. The findings in A and B were verified by the Director of Surgical Services on 01/25/22 at 1:38 PM.


42990

Based on review of CDC (Center for Disease Control) Guidelines, review of product Safety Data Sheet, observation and interview, it was determined the facility failed to maintain a sanitary environment for two of two (Room #2 and Room #10) inpatient rooms by not assuring cloth furniture was not available for patient/visitor use. By not assuring only furniture that could be wiped down and sanitized between use was available, the facility could not assure pathogens were not present on inanimate objects in the patient care area. The findings had the potential to affect any patients receiving care in room #2 and #10. Findings follow:

A. Review of CDC's Best Practice for Environmental Cleaning in Healthcare Facilities, furnishings with materials that hold moisture, such as wood, cloth, seams, and upholstered furniture should be avoided in patient care areas.
B. Review of Safety Data Sheet for Clorox Commercial Solutions Clorox Total 360 Pro Electrostatic Mister spray showed no indication that it was safe for use on cloth furniture.
C. During a tour of the Medical/Surgical Unit on 1/26/22 at 11:10 AM one cloth loveseat and one cloth chair was observed in one of one (Room #10) inpatient room available for use.
D. During a tour of the Medical/Surgical Unit on 1/26/22 at 1:35 PM one cloth loveseat and two cloth chairs were observed in one of one (Room #2) inpatient room available for use.
E. In an interview with the DON (Director of Nursing) at the time of the observations, she confirmed the cloth furniture available for use and stated that they were using a portable Clorox Pro Electrostatic Mister to spray on the furniture and confirmed they were not wiping down the furniture.

Based on policy and procedure review, observation, review of product label, and interview, it was determined the facility failed to maintain a sanitary environment on the Medical/Surgical Unit by not assuring expired supplies were not available for patient use. Failure to ensure only currently dated supplies were available for use did not assure the supplies were free from contaminates and safe for patient use. The failed practice had the potential to affect all patients receiving care on the Medical/Surgical Unit. Findings follow:

A. Review of Infection Control Policy and Procedure showed, "Quarterly checks will be done for outdated sterile supplies ..."
B. During a tour of the Medical/Surgical Unit Clean Supply Room on 1/25/22 at 1:30 PM, the following supplies were observed to be expired:
1. #6-Anti-Embolism Elastic Stockings Knee Hi Small Regular expired 12/5/19
2. #2-Large Volume Abdominal Paracentesis Kit expired 8/31/21
3. #1-Arrow-Clarke Pleura-Seal Thoracentesis Kit expired 6/30/18
4. #2-Oasis Dry Suction Water Seal Chest Drain expired 1/19
5. #1-Thoracostomy Procedure Tray expired 7/19
C. The above findings were verified by interview with the DON (Director of Nursing) at the time of the observation.

Based on review of the Association of periOperative Registered Nurses (AORN) Guidelines (2016), observation, and interview, it was determined the facility failed to maintain a sanitary environment in that staff did not follow ARON Guidelines for reprocessing stored endoscopes for 4 of 4 endoscopes within the seven-day maximal storage time frame. Failure to follow accepted professional guidelines did not assure patients having endoscopy procedures were protected from infection and had the potential to affect all patients having endoscopy procedures in the facility. Findings follow:

A. Review of AORN Guidelines showed, "The researchers concluded that when correctly processed and stored, flexible endoscopes were safe to use for a period of 7 days before reprocessing."
B. Observation of the Endoscope Reprocessing Room on 1/25/22 at 11:40 AM, showed no process or system for reprocessing used endoscopes.
C. In an interview with ST (Surgical Technician) #1 on 1/25/22 at 11:40 AM, she stated that the endoscopes were used daily, so they were reprocessed after each use but if for some reason they did not get used daily they were reprocessed about every 14 days.
D. In an interview with the OR Manager on 1/26/22 at 10:40 AM she confirmed the facility follows AORN Guidelines and they do not have a process for ensuring the endoscopes are cleaned every 7 days if they are not used

Based on review of manufacturer's directions for use, observation and interview it was determined the facility failed to maintain a sanitary environment in the cleaning and storage of 4 of 4 endoscopes by reusing single use sponges and storing reprocessed endoscopes with a Ruhof Dry Sponge on the distal tip. Failure to clean and store reprocessed endoscopes according to manufacturer's instruction did not assure the endoscopes would be free from pathogens and bioburden and had to potential to affect all patients having endoscopic procedures. Findings follow:

A. Review of Ruhof Dry Sponge directions for use showed, "Scope Cleaning: 1. Remove sponge from plastic bag. 2. Place sponge around the insertion tube of scope or tubular instrument. 3. Run sponge down length of scope or instrument to remove gross soil. 4. Rinse sponge and repeat until surface is clean. 5. Discard sponge."
B. Review of Ruhof Dry Sponge Directions for Use showed, "Warning: Never use Ruhof Dry Sponge on a disinfected or sterilized endoscope and/ or medical/surgical instrument."
C. During observation of endoscope cleaning and storage in the Endoscope Reprocessing Room on 1/25/22 at 11:25 AM, the surveyor observed ST (Surgical Technician) #1 take a sponge off of the sink faucet and use the sponge to clean 1 of 1 Colonoscope.
D. During observation in the Endoscope Reprocessing Room the surveyor noted 3 of 3 Endoscopes hanging in the Endoscope Drying Cabinet with Ruhof Dry Sponges on the distal tip of the scope.
E. In an interview with ST #1 in the Endoscope Reprocessing Room on 1/25/22 at 11:26 AM, the surveyor asked ST #1 if the sponge on the faucet had been used on other endoscopes and ST #1 stated yes that the process was to use the same sponge to clean endoscopes all day and to discard the sponge at the end of the day.
F. In an interview with ST #1 in the Endoscope Reprocessing Room on 1/25/22 at 11:38 AM, the surveyor asked why the Ruhof Dry Sponges were on the distal ends of the endoscopes in the Endoscope Drying Cabinet and she stated the sponges were used to protect the tip of the endoscopes from damage.
G. In an interview with the OR Manager on 1/26/22 at 10:40 AM, she confirmed the findings above in A, B, C, D, E, and F.

Based on observation and interview, it was determined the facility failed to assure a sanitary environment in the Outpatients Services and Medical/Surgical areas in that cotton balls were not individually packaged and available for patient use. The failed practice did not assure patients would be free from potential sources of infection. Findings follow:

A. During a tour of 1 of 1 Outpatient Services Exam Room on 1/25/22 at 1:13 PM, a clear glass jar was observed to contain cotton balls not individually packaged and available for anyone to reach in the jar and get the cotton balls for use.
B. During a tour of the Medical/Surgical Unit Medication Station on 1/25/22 at 1:30 PM, a clear glass jar was observed to contain cotton balls not individually packaged and available for anyone to reach in the jar and get the cotton balls for use.
C. In an interview at the times of the observations, the DON (Director of Nursing) confirmed the findings in A and

Based on review of the Emergency Preparedness Plan and interview, it was determined the facility did not develop policies and procedures outlining the use of volunteers, how the volunteers would be qualified, what duties the volunteers could perform, and who would authorize the use of volunteers in the event of an emergency or disaster. Failure to develop a policy and procedure which defined the use, qualifications, duties, and who had the authority to authorize the use of volunteers could result in the delay of care for injured individuals in the event of an emergency. The failed practice had the potential to affect all patients, staff, and community members in the event of an emergency. Findings follow:

A. Review of the Emergency Preparedness Plan did not show policies and procedures which outlined the use of volunteers in the event of a disaster or emergency.
B. The findings in A were verified during an interview with the Safety Officer on 1/27/22 at 9:50 AM.

Based on interview and review of the Emergency Preparedness Plan, it was determined there was no evidence the Emergency Preparedness Plan included provision of care and treatment at an alternate site and coordination efforts needed during a declared emergency when the 1135 Waiver is enacted by the Secretary. The failed practice had the likelihood to affect all patients and staff in that there was no procedure to ensure the staff would be knowledgeable on what to do during a declared 1135 waiver by the Secretary. The findings were:

A. Review of the Emergency Preparedness Plan showed there was no evidence the Emergency Preparedness Plan addressed the provision of care and treatment at an alternate site and coordination efforts needed during a declared emergency when the 1135 Waiver had been enacted by the Secretary.
B. The findings in A were verified during an interview with the Safety Officer on 1/27/22 at 9:50 AM.