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Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the fire rated doors were maintained in a manner to ensure the safety and well-being of patients in that:
1) The fire rated door closer was placed on the door when closed; and
2) The correct type of fire rated doors were not being used throughout the facility.
The failed practice did not ensure the safety of patients and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observation of the supply room in the Emergency Department next the the Lab on 12/04/2023 at 2:12pm showed to have a regular door being used instead of a fire rated door.
B. Observation of Radiology Department on 12/04/2023 at 3:09 pm showed to have a fired rated door that was missing a door closer.
C. Observation of the 3rd Floor on 12/04/2023 at 3:16 pm showed regular doors being used in several locations instead of fire rated doors on a fire wall near doctors quarters.
D. Observation of the Operating Suite on 12/04/2023 at 3:40 pm showed to have regular door frames being used instead of fire rated door frames and all doors on the fire wall did not have door closers.
E. The findings A-D were verified with the Head of Maintenance on 12/04/2023 at 3:40 PM.

Based on observation of the kitchen, Fourth Floor and Labor and Delivery and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Finding follow:

A. Observation of the dirty utility closet across from Emergency Room 2 on 12/04/2023 at 3:00 PM showed to not have and exhaust fan.
B. Observation of the Enviornmental Services room on 12/04/2023 at 2:47 pm in the Emergency Department showed to have boxes and supplies stored on the floor.
C. Observation of the door on 12/04/2023 at 2:49 pm of the laboratory department showed to have a brick placed in front of it preventing full closure of the door.
D. Observation of the Supply Room on 12/04/2023 at 2:52 pm showed to have an exhaust fan that didn't work.
E. Observation of medical gas storage on 12/04/2023 at 2:55 pm showed to have an Oxygen tank that was not secured.
F. Observation of the exit doors in the Emergency Department on 12/04/2023 at 2:55 pm showed to have damaged weather stripping that needed to be replaced.
G. Observation of Operating Room #1 on 12/04/2023 at 4:17pm showed to have a damaged light.
H. Observation of the Sterile Room in the Operating Suite on 12/04/2023 at 3:19 pm showed to have an open ceiling tile.
I. The findings A-H were verfied by the head of Maintenance on 12/04/2023 at 3:20 PM.

Based on observation and interview, it was determined the facility failed to ensure safety from fire in that there was no emergency stop switch placed 10-15 feet away from the emergency generator and also there was no emergecy light installed on the generator. The failed practice placed the patients at risk of fire and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Observation of the generator on 12/04/2023 at 4:20 pm showed that there was no emergency stop switch installed 10-15 feet away from the emergency generator
B. Observation of the generator on on 12/04/2023 at 4:20 pm showed that there was no emergency light installed on the emergency generator
C. Findings A-B were verified with the Head of Maintenance on 12/04/2023 at 4:20 pm.

Based on observation, review of Arkansas Department of Health Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances, 12/01/2014 and interview, it was determined the facility failed to follow accepted professional principles in that they wasted pharmaceutical narcotics in the sharps container instead of into a receptacle that would render them non-retrievable in one of one Surgical Services toured. By not wasting the narcotics according to accepted professional principles, the facility was not in compliance with Arkansas Department of Health's Pharmacy Services and Drug Control Branch's Rules and Regulations Pertaining to Controlled Substances. The failed practice had the likelihood to affect all medications wasted in the facility. Finding follow:

A. Record review of Arkansas Department of Health Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances 12/01/2014 showed narcotic waste should have been disposed of in a receptacle that would render them non-retrievable.
B. During a tour of Surgical Services on 12/04/23 from 3:16 PM to 3:55 PM, observation showed no designated narcotic wastage receptacle that would render the waste unretrievable.
C. During an interview on 12/04/23 at 3:30 PM, while touring the Post Anesthesia Care Unit, the Interim Operating Room Manager was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
D. During an interview on 12/04/23 at 3:39 PM, while touring the Medication Room, the Interim Operating Room Manager was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
E. During an interview on 12/04/23 at 3:45 PM, while touring Operating Room #3, the Interim Operating Room Manager was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
F. During an interview on 12/04/23 at 3:49 PM, while touring Operating Room #1, the Interim Operating Room Manager was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.


Based on review of policy, review of the Rules for Critical Access Hospitals in Arkansas (2022), observation and interview, it was determined the facility failed to follow accepted professional principles in that an emergency cart was not secured with a break away seal on one of one (Emergency Malignant Hyperthermia) kit observed. By not securing the cart with a breakaway seal, the facility could not assure the contents of the cart would be available for an emergency. The failed practice had the likelihood to affect all patients who needed Emergency Malignant Hyperthermia medications. Finding follow:

A. Record review of policy titled, "Emergency Kits," Reviewed 03/2023, showed the integrity of the kit can be easily identified if opened or compromised (through the use of locks or tamper resistant packaging).
B. Record review of the "Rules for Critical Access Hospitals in Arkansas (2022) Section 12.S.4," showed that emergency type medications were to be secured with a breakaway seal.
C. During a tour of Surgical Services on 12/04/23 from 3:16 PM until 3:55 PM, observation showed the Malignant Hyperthermia emergency cart was unlocked and it was not secured with a breakaway seal.
D. During an interview on 12/04/23 at 3:39 PM, the Interim Operating Room Manager verified the emergency Malignant Hyperthermia medications were being stored in a kit that was not secured with a break away seal.

Based on policy and procedure review, observation, and interview, it was determined the facility failed to ensure food storage areas were monitored for temperature in that there were no temperatures recorded for three of three (the walk-in refrigerator in the kitchen, the walk-in freezer in the kitchen, or the reach in refrigerator in the kitchen) refrigerators. The failed practice placed the patients at risk of food-borne illness and had the likelihood to affect all patients receiving food from the kitchen. Findings follow:

A. Review of policy and procedure titled "Temperatures of Refrigerators and Freezers" showed the supervisor will monitor storage temperatures as follows: temperatures were to be recorded at the opening and closing of the day for each storage area.
B. Observation during a tour of the dietary services on 11/5/2023 at 1:15 PM showed:
1) The kitchen reach in refrigerator did not have consistent daily temperatures logged for October and November 2023. An example was on 10/1/2023 there were only afternoon temperatures logged instead of one for the morning and one for evening.
2) The kitchen walk in refrigerator did not have consistent daily temperatures logged for October and November 2023. An example was on 10/20/2023 there were only morning temperatures logged instead of one for the morning and one for evening.
3) The kitchen walk in freezer did not have consistent daily temperatures logged for October and November 2023. An example was on 11/27/2023 there were only morning temperatures logged instead of one for the morning and one for evening.
C. Observation of dietary services on 11/5/2023 at 1:40 PM showed two white chest freezers full of frozen meat and vegetables that did not have a log of temperatures.
D. During an interview with Assistant Manager of Food Services on 11/5/2023 at 1:45 PM, the findings in A, B, and C were verified.


Based on policy and procedure review, observation, and interview, it was determined the facility failed to assure four of four containers of salad dressings, and eight of eight loaves of bread were not available for use in the Dietary Department past the manufacturer's expiration date. Failure to remove items according to the manufacturer's date of expiration did not assure the contents of the expired food items were suitable for patient consumption. The failed practice had the likelihood to affect all patients admitted to the facility. Findings included:

A. Review of policy and procedure titled "Physical Environment" showed all perishable foods that have passed their expiration date were removed from service. All expired foods are to be discarded promptly. All food was to be rotated so that the first in will be the first out.
B. Observation on 11/5/2023 at 1:50 PM in the reach in refrigerators of the Dietary Department showed four of four containers of salad dressings that expired on 5/2023.
C. Observation on 11/5/2023 at 1:52 PM in the reach in refrigerators of the Dietary Department showed three of three cheesecake desserts, shredded lettuce in stainless steel containers, coleslaw in stainless steel container, cut fresh fruit in stainless steel container, and a jar of dill pickles without dates to identify first in first out.
D. Observation on 11/5/2023 at 2:00 PM in the walk-in freezers of the Dietary Department showed eight of eight loaves of bread that expired on 4/2022.
E. During an interview with Assistant Manager of Food Services on 11/5/2023 at 2:20 PM, the findings in A, B, C, and D were verified.


Based on policy and procedure review, observation, and interview, it was determined the facility failed to maintain a log of wash and rinse water temperatures and sanitizer parts per million (ppm). Failure to maintain a daily log of the temperatures and sanitizer usage did not ensure the dishes were cleaned per the policy. The failed practice had the likelihood to affect all patients admitted to the facility. Findings included:

A. Review of policy and procedure titled "Dish Machine" showed that food services staff were to check the machines wash and rinse water temperatures and sanitizer ppm and record information on each shift.
B. Observation during a tour of the dish washing room in Dietary Services 11/5/2023 at 2:05 PM, showed there was only a log from June 2023 on a shelf. A request was made to the Assistant Manager of Food Services for the last five months (July through November) of logs. No other dish washing room logs were provided.
C. During an interview with Assistant Manager of Food Services on 11/5/2023 at 2:20 PM, the findings in A and B were verified.

Based on review of the Rules for Critical Access Hospitals in Arkansas, 2022, Sections 21 and 22, review of Rehabilitation Staff personnel files and interview, it was determined the facility failed to follow the standards of practice in the organization of Rehabilitation Services in that three (#2, #3 and #4) of four (#1-#4) Physical Therapists and two (#1 and #4) of five (#1-#5) Occupational Therapists did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that received Physical and Occupational Rehabilitation Services. Findings follow:

A. Record review of the Rules for Critical Access Hospitals in Arkansas, 2022, Sections 21.J and 22.K showed all physical and occupational therapy personnel who participate in direct patient care shall be competent in life support measures.
B. Review of Rehabilitation Staff personnel files showed the following:
1. Physical Therapists #2, #3 and #4's files showed no evidence of a current CPR certification. Their CPR certifications expired 06/21, 08/21 and 10/21 respectively.
2. Occupational Therapists #1 and #4's files showed no evidence of a current CPR certification. Occupational Therapist #1's had expired 08/21 and Occupational Therapist #4 was not previously certified and was a new hire.
C. During an interview on 12/05/23 at 3:29 PM, the Director of Human Resources verified the findings at B.

Based on observation and interview, it was determined the facility failed to assure the environment was free from tape, and tape residue on the door between Emergency Room 1 and Emergency Room #2 and on the wall at the head of the bed in Emergency Room #2. The failed practices did not assure contamination did not occur as tape and tape residue cannot be disinfected. This failed practice had the likelihood to affect all persons treated in these two rooms. Findings follow:

A. During a tour on 12/4/2023 from 3:00 PM to 4:15 PM it was observed that the door between Emergency Room #1 and Emergency Room #2 was covered with a plastic sheet taped to the doorjamb and clear tape was holding supplies to the wall at the head of the bed.
B. The findings in A were confirmed with the Emergency Room Manager at on 12/4/2023 2:55 PM.


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Based on observation and interview, it was detemined that the facility failed to ensure patient supplies were not available for use after the manufacturer's expiration date. The failed practice could not guarentee the sterility of the packaged supplies and had the likelihood to affect all patients in Emergency Room Trauma I. The findings follow:

A. During a tour of Emergency Room Trauma 1 on 12/04/23 at 2:42 PM, showed 9 of 9 extension flow dial sets with expiration dates of 8/30/22.
B. The above findings in A were verified with the Director of Nursing on 12/04/23 at 2:50 PM.


Based on observation and interview, it was detemined that the facility failed to ensure patient supplies were not available for use after the manufacturer's expiration date for three of three nasopharyngeal airways. The failed practice did not ensure the sterility of the patients supplies and had the likelihood to affect all patients admitted to the facility. The findings follow:

A Observation during a tour of Post- Anesthesia Care Unit Room 2 on 12/04/23 at 3:26 PM, showed 3 Nasopharyngeal airways with expiration dates of 6/30/23.
B.The findings in A were verified with the Director of Nursing on 12/04/23 at 3:30 PM.