HospitalInspections.org

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the Nursing Department performed and documented emergency equipment checks on equipment for one (1) of four (4) crash carts observed (Special Care Room) and failed to execute preventative maintenance (PM) on one (1) of one (1) Oximax Nellcor portable oxysensor (portable multi use device used to monitor oxygen concentration in the blood) located in the Special Care room. These deficient practices have the potential to place all patients at risk for insufficient emergency care resulting in possible harm and poor outcomes.

Findings Include:

- Observation in the Special Care Room on 9/25/2017 at 2:45 PM revealed the staff failed to run a performance check of the heart defibrillator (device used in emergencies to send an electric shock to the heart in an effort to restore its natural rhythm) a total of 37 out of 87 days, from July, 2017 through September, 2017. Failure to perform and document defibrillator checks occurred on the following dates:

7/15/17, 7/16/17, 7/18/17, 7/19/17, 7/20/17, 7/21/17, 7/22/17, 7/23/17, 7/24/17, 7/25/17, 7/26/17, 8/1/17, 8/2/17, 8/3/17, 8/9/17, 8/10/17, 8/12/17, 8/13/17, 8/16/17, 8/17/17, 8/18/17, 8/24/17, 8/25/17, 8/26/17, 8/27/17, 8/30/17, 8/31/17, 9/6/17, 9/7/17, 9/8/17, 9/9/17, 9/10/17, 9/11/17, 9/13/17, 9/22/17, 9/23/17, and 9/24/17.

Interview with Trauma Director Registered Nurse (RN) Staff D acknowledged the missed defibrillator checks and stated nursing personnel are responsible for daily checks of the emergency equipment.

Policy titled "Zoll M Series Monitor, #13524" directed, Defibrillator check is to be tested daily. If test failure take out of service and report to ER Manager.


- Observation in the Special Care Room on 9/25/2017 at 2:45 PM revealed the staff failed to ensure preventative maintenance was implemented on the oxysensor.

Interview with Pharmacy RN Staff C on 9/25/2017 at 2:50PM acknowledged the PM had not been performed.


Policy titled "New Equipment Safety Checks and Preventative Maintenance/Defective Equipment/Biomed" directed, ...Planned maintenance will be assigned to the equipment... ...for entry on the capital equipment list, it applies... ...Bio-Med performs a 2x a year inspection of all facility life safety equipment.

Based on staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure the Kansas State food code regulations were implemented for preventing the potential contamination of food when an airgap was not installed on the kitchen preparation sink to prevent the backflow of sewage, gas or other contaminates. This failed practice potentially placed all staff, patients, and visitors at risk for food contamination.

Findings include:

According to the "Kansas State Food Code 2012" regulation 107 5-203.14 Backflow Prevention Device, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT (includes, but is not limited to: ...cafeterias, public or nonprofit organizations routinely serving food).


Maintenance Staff B interviewed in the conference room on 9/25/2017 at 12:50 PM verified the facility kitchen preparation sink failed to have a backflow device installed.

- The CAH failed to develop and implement a policy regarding a Backflow device for the kitchen preparation sink.


.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to safely store all medications in two (2) of seven (7) observations. Failure to continuously secure all medications preventing access by unauthorized staff, patients, and visitors places the CAH at risk of security breach.

Findings include:

- Observation in the Pharmacy on 7/25/2017 at 1:30 PM revealed an unlocked door into the room housing the main Omnicell (computerized medication dispensing system) on one wall and a bank of 4 locked upper and lower cabinets along the opposite wall. During the observation, 3 different employees were observed entering and exiting the room after obtaining medications from the Omnicell. A sealed tray containing emergency medications used for replacement of medications in the crash carts was stored unsecured on top of the Omnicell unit.

Interview with Pharmacy Registered Nurse (RN) Staff C on 7/25/2017 at 1:45 PM confirmed that they stored the sealed medication replacement tray on top of the Omnicell. She stated it was prepared and rotated as a replacement for an open crash cart tray and acknowledged that it was stored in an unsecured area.


- Observation in patient room #7 at 10:15 AM of RN Staff H revealed Patient #3 sitting in chair in room. RN Staff H pushed the computer on wheels (COW) into the patient room next to Patient #3, opened the drawer of the cart and removed medications from the drawer, opening and placing them into the medication cup on the work surface of the COW. RN Staff H then left the room. The medications were left on the work surface and the COW drawer was left open, leaving all medications available to unauthorized access.

Interview with RN Staff H confirmed that s/he did leave the medications unattended when s/he left the room.

The CAH was unable to provide a policy regarding safe storage of medications.

Based on observation, staff interview, policy and procedure review the Critical Access Hospital (CAH) failed to ensure temperatures for 1 of 1 Operating Room (OR) and 1 of 1 Procedure Room were in range (68-73 degrees Fahrenheit (F)) and corrected if out of range, failed to ensure the temperature for 1 of 1 OR Blanket Warmer was at normal range (130 degrees F), failed to verify that food products and physical therapy (PT) therapeutics (cold packs) are stored under appropriate conditions and manufacturer's recommendations. Failure to ensure OR and Procedure room temperatures are within safe and effective ranges for surgeries and procedures puts all patients at risk for receiving surgeries and procedures to prevent illness and diseases related to bacteria and pathogen contamination, puts all patients at risk for burns, and puts all patients at risk for burns. for foodborne diseases related to elevated refrigerator temperatures and PT patients at risk for tissue damage.

Findings include:

- Observation in the surgical area on 9/26/2017 at 10:07 AM revealed the Procedure room temperature logs for August and September 2017 revealed 20 of 30 recorded temperatures below the required temperature guidelines of 68-73 degrees F. The following recorded temperatures of 66 degrees F were documented on August 8, 9, 14, 16, 17, 22, 23, 24, 28, 29 and 30th, and September 5, 6, 12, 13, 14, 18, 19, 20, and 21st. Review of the OR room temperature logs for August and September 2017 recorded revealed 28 of 30 recorded temperatures below the required temperature guidelines of 68-73 degrees F. The following recorded temperatures of 66 degrees F were documented for August 1, 2, 8, 9, 10, 14, 15, 16, 17, 21, 22, 23, 24, 28, 29, 30, and 31, and September 5, 6, 11, 12, 13, 14, 18, 19, 20, 21, and 25th.

Registered Nurse (RN) Staff T interviewed in the surgical area on 9/26/2017 at 10:07 AM verified the Procedure and OR room temperature logs for August and September 2017 with the recorded out of range temperatures.


The CAH's policy titled "Safe Environment of Surgical Care" directed, ...temperature 68-73 degree F for the operating room...surgery staff will record the temperature daily and report any variance to Maintenance.


- Observation in the surgical area on 9/26/2017 at 10:07 AM revealed the blanket warmer temperature logs for August and September 2017 revealed recorded temperatures out of range for 14 of 30 recorded temperatures. The temperatures for August 2017 were 134 F on August 1, 2, 3, and 23, and 131 F on the 24th. The temperatures for September 2017 were 131 F on September 7, and 11, 132 F on September 12, 13, 14, and 18th, 133 F on September 20th and 134 F on September 21st.

RN Staff T interviewed in the surgical area on 9/26/2017 at 10:07 AM verified the blanket warmer temperature logs for August and September 2017 revealed recorded temperatures out of range.

The CAH's policy titled "Safe Environment of Surgical Care" directed, ...the blanket warmer cabinet temperature will not exceed 130 degrees F.


- Observed temperature graph of the west refrigerator from 8/1/2017 through 8/15/2017 revealed many incidents (too many to count) of elevated out of range temperatures.


Interview with Dietary Staff CC on 9/26/2017 at 2:00 PM regarding temperatures of the west refrigerators, Staff stated there is no documentation of an intervention when the temperatures of the refrigerator are out of range.

The CAH dietary staff failed to provide a policy regarding refrigerator temperatures or interventions for temperatures outside the monitored range.

...chilling food to temperatures below 41 degrees is the best way to ensure that food does not sit in the danger zone. The more time food sits in this temperature range, the more opportunity there is for bacteria to grow to unsafe levels, causing food to spoil and become dangerous for consumption." The Danger Zone: Following Food Safety Temperatures.


- Observation of the freezer area in the refrigerator in the Physical Therapy (PT) department revealed cold packs for patient use. There was not a thermometer in the freezer.

Interview with Physical Therapy Staff Z on 9/26/2017 at 11:00 AM, Staff stated temperatures in the freezer are not being recorded or monitored.

The CAH physical therapy staff failed to provide a policy regarding the monitoring or recording of the freezer temperatures.


The use of ice packs in treatment decreases the blood flow, this occurs as a result of vasoconstriction. Patients with poor thermoregulation, Raynaud's disease or open wounds should be monitored closely during treatment with an ice pack.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the Medical Staff credentialing for re-appointments with privileges were updated in the required time set forth by the Governing Body for four (4) of fifteen (15) medical staff members (Staff EE, II, JJ, KK), failed to complete a national practitioners data bank inquiry (assembled to compile the names and profiles of providers who have been charged with, convicted or subject to punishment for "unprofessional behavior") for one (1) of fifteen (15) medical staff members (Staff GG) and failed to ensure every medical staff member maintained a current medical license in one (1) of fifteen (15) credentialing files reviewed (Staff KK). These deficient practices have the potential to allow medical staff to provide unsafe care resulting in poor patient outcomes.

Findings Include:

- Observation of Medical Staff Credentialing files reviewed on 9/26/2017 at 2:00PM revealed the Governing Body had not completed and approved reappointment credentials for Physician Staff EE within the CAH's established 2 year timeframe.

- Observation of Medical Staff Credentialing files reviewed on 9/27/2017 at 10:10AM revealed the CAH failed to show evidence of a national practitioner's data bank inquiry for Physician Staff GG.

- Observation of Medical Staff Credentialing files reviewed 9/26/2017 at 2:00PM revealed the Governing Body had not completed and approved reappointment credentials for Physician Staff II within the CAH's established 2 year timeframe.

- Observation of Medical Staff Credentialing files reviewed 9/26/2017 at 2:00PM revealed the Governing Body had not completed and approved reappointment for medical staff priviliges including documentation of their scope of practice for Advanced Practice Registered Nurse (APRN) JJ within the CAH's established 2 year timeframe.

- Observation of Medical Staff Credentialing reviewed 9/26/2017 at 2:00PM revealed the Governing Body had not completed and approved reappointment credentials for Doctor of Dental Medicine Staff KK within the CAH's established 2 year timeframe.

Interview of Chief executive Officer (CEO) Staff R on 7/27/2017 at 9:00 AM confirmed the missing documentation and stated the Board had approved the reapplications as noted in the Governing Body meeting minutes but the individual credentialing files lack the documentation of individual restrictions for each application and notification of reapplication approval to each credentialed individual.


- Observation of Medical Staff Credentialing files reviewed on 9/26/2017 at 2:00 PM revealed Doctor of Dental Medicine Staff KK lacked evidence of a current dental license.on file with the CAH.

Interview of CEO Staff R on 7/27/2017 at 9:00 AM confirmed the missing license for Staff KK.


Document titled "Governing Body Bylaws" Section 1 and 2 directed, ...No physician or dentist shall admit or provide medical or health related services to any patient in the Hospital unless he or she has been appointed to the Medical Staff or been granted temporary privileges... ...Membership of the Medical Staff shall be for a period of two (2) years.

Document titled "Medical Staff Bylaws" Credentials Committee Section 9.3 directed, The duties of the Credentials Committee shall be: (i) to review the credentials of all Applicants and to make recommendations to the Medical Executive Committee for membership and delineation of Clinical Privileges... ... (ii) To review at least every two (2) years all information available regarding the qualifications and competence of Staff members.

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure outdated, unusable medications were removed and made unavailable for patient use in one of one Labor and Delivery Rooms (LDR), one of one Special Care Room, one of one Surgical Suites (OR), one of one Radiology Suites, one of one Emergency Department rooms, one of four crash carts (Computerized Tomography (CT) room, and one of one anesthesia cart. The deficient practice of failure by the CAH to remove outdated medications places all patients at risk for receiving ineffective medications and IV fluids resulting in unsafe care.

Findings Include:

- Observation of the LDR Room on 7/25/2017 at 12:45 PM revealed the following outdated medications:
- 1, 10 cc (milliliter) vial Sodium Chloride (a solution with fluid and electrolyte replacement), outdated 8/1/2016
- 1, 10 cc prefilled Sodium Chloride syringe, outdated 7/2017

Registered Nurse (RN) Staff E acknowledged the outdated medications and removed them from the room.


-Observation of the Special Care Room Crash Cart on 7/25/2017 at 2:45 PM revealed the following outdated medications:
- 1, 100ml (Milliliter) bag Sodium Chloride IV fluid, outdated 5/2015

Pharmacy RN Staff C acknowledged the outdated medication and removed it from the patient care room.


Policy titled "Outdated /Deteriorated Pharmaceuticals and Formula, #911" directed, All licensed personnel using pharmaceuticals...Before using any pharmaceutical, visually check the contents of vial, amp, syringe, etc. for date... ...Each department head should be ever vigilant for outdating items and alert the Pharmacy RN if any pharmaceutical dating is imminent... ...Pharmacy RN or designated person will inspect hospital stock in locations not using Omnicell systems monthly and record the items that will be outdating... ...Any item that will outdate before a month is over should be recorded for the previous month... ...Check stock at the end of each month, removing and replacing the items that are outdating... ...Remove outdates from all storage areas the last week of the month when the medication will outdate.


- Observation on 9/26/2017 at 3:08 PM in the CT room of radiology revealed in the crash cart outdated saline flushes and IV fluids which included:
2 - Normal Saline (solution for fluid and electrolyte replenishment) flush 5ml (milliliters), outdated 10/2015
1 - Normal Saline (solution for fluid and electrolyte replenishment) flush 5ml (milliliters), outdated 3/2015
2 - Normal Saline (solution for fluid and electrolyte replenishment) flush 5ml (milliliters), outdated 12/2016
1 - 10% Dextrose (solution that provides lost fluids and carbohydrates to the body) 1000ml, outdated 3/2015
1 - Lactated Ringers (solution for fluid and electrolyte replenishment) 1000ml, outdated 2/2015
1 - 5% Dextrose 0.225% Normal Saline (solution for fluid, carbohydrate and electrolyte replenishment) 1000ml, outdated 3/2016
1 - 5% Dextrose 0.45% Normal Saline 1000ml outdated 1/2015
1 - Normal Saline 250ml, outdated 1/2016
1 - Normal Saline 5000ml, outdated 6/2015
1 - Normal Saline 1000ml, outdated 3/2015
1 - Normal Saline 340ml for oxygen inhalation humidifier, outdated 7/2016

Interview with staff X on 9/26/2017 at 3:20 PM confirmed and verified the outdates while in the CT room of Radiology


- Observation on 9/26/2017 at 9:43 AM in the Operating Room (OR) in the anesthesia cart revealed outdated medications which included:
1 - Metoprolol tartrate (used to lower blood pressure or heart rate) 5mg (milligrams)/5ml, outdated 9/1/2017
1- Lasix (helps to reduce fluid in your body) 40mg/4ml, outdated 4/1/2017
2 - Diphenhydramine (used to treat an allergic reaction) 50mg/ml, outdated 6/2017

Interview with staff AA on 9/26/2017 at 9:50 confirmed and verified the outdates in the OR room.

The CAH's policy titled "Outdated/Deteriorated Pharmaceuticals" reviewed on 9/28/2017 directed, ...each department should be ever vigilant for outdated items...and remove outdates from all storage areas.

The Centers for Disease Control and Prevention (CDC) Basic Infection Control and Prevention Plan showed, ..Medications should always be discarded according to the manufacturer's expiration date (even if not opened).

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure expired supplies were removed from one of one Emergency Department (ED) treatment room, one of one ED Crash Cart, one of one ED Broselow Cart, one of one Labor and Delivery room (LDR), and one of one Special Care room, one of one Special Care crash cart, one of one Special Care airway kit, two of two floor storage areas, one of one central supply rooms, one of one Computerized Tomography (CT) room, one of one Operating Room (OR) anesthesia cart, and one of one OR room storage cabinets and shelves.

The CAH failed to ensure patient care equipment was cleaned after each use for one of one stethoscopes (a tool used by doctors and nurses to listen to heart and lung sounds) in the Pre-Operation Room and one of one pulse oximetry (equipment used to measure patients percentage of circulating oxygen) (Registered Nurse (RN) Staff H).

The CAH failed to enforce clean gloves were worn for processing one of one Colonoscopy's (a flexible tube with a camera and a light on the end to look at the colon) and one of one terminal (final) cleaning of procedure room Tech Staff N).

The CAH failed to provide personal protective equipment (PPE) in one of one Special Care rooms and one of one laboratory.

The CAH failed to ensure splash guards are installed in 1 of 1 surgical hoppers observed (Special Care Room) and failed to have PPE equipment available in 1 of 1 rooms with a hopper installed (Special Care Room).

The CAH failed to provide personal protective equipment (PPE) in all areas that cross contamination of body fluids is possible (Laboratory).

The CAH failed to remove patient care items and biohazard materials from beneath the sink in one of one Special Care rooms.

The CAH failed to ensure hand hygiene was performed during one of one procedures performed (Registered Nurse (RN) Staff K).

The CAH failed to ensure disinfectant of an Intravenous (IV) hub was performed before connecting the IV tubing (RN Staff K).

The CAH failed to provide cleanable surfaces of three of three chairs in the cardiac rehabilitation department, and the CAH failed to ensure use of hairnets when entering the kitchen.

The CAH failed to ensure all staff in the food preparation area wore hair coverings (two unknown non-dietary staff),

These deficient practices puts all staff and patients at risk for an unsafe and unsanitary environment free of bacteria causing illness and diseases.

Findings Include:

- Observation in the Emergency Department (ED) cabinets on 9/25/2017 at 1:54 PM revealed the following expired supplies:

1-Xeroform (a sterile petroleum gauze used in wound care), outdated 7/2017
4-Xeroform, outdated 3/2016
1-Nasal Rocket (used to treat nosebleeds in children and adults), outdated 10/2016
1-Betadine (an antiseptic used to disinfect skin before and after surgery), outdated 10/2016
2-Betadine, outdated 2/2017
1-needle set, outdated 12/2016
3-intravenous (IV) transfer set (used to insert into a vein to give fluids and medications), outdated 4/2016
2-15 millimeter (mm) 15 gauge (g) (measurements of needles) needle sets, outdated 10/2016
2-45mm x 15g needle sets, outdated 12/2016
1-25mm x 15g needle set, outdated 5/2016
2-25mm x 15g needle sets, outdated 12/2016
1-18" coated sutures (stitches used to hold together the edges of a wound or surgical incision), outdated 7/2017
2-18" sutures, outdated 1/2017

Interview of RN Staff D in the ED by the cabinets on 9/25/2017 at 1:54 PM verified the outdated supplies.

- Observation of the ED Crash Cart in the ED room on 9/25/2017 at 2:07 PM revealed the following expired supplies:

1-18" sutures, outdated 1/2017
1-25g x 5/8" needle, outdated 11/2013
3-packages of alcohol swab sticks (used to clean the skin), outdated 2/2016.

Interview of RN Staff D in the ED room at the ED Crash Cart on 9/25/17 at 2:07 PM verified the outdated supplies.

- Observation of the Broselow Cart (a cart with emergency supplies used on children in the case of emergencies) in the ED room on 9/25/17 at 2:21 PM revealed the following expired supplies:

2- Cuffed 6.5mm tracheostomy tubes (trach tubes - a curved tube inserted into a hole made in the neck), outdated 6/2016
5-24g x ½" needles, outdated 3/2017
6-0.9% Sodium Chloride (a salt water solution) prefilled syringes, outdated 3/2017
2- 6.0mm cuffed trach tubes, outdated 11/2016
1-4.5mm trach tube, outdated 10/2016
1-18g x 1 1/16" needle, outdated 9/2017

Interview of RN Staff D in the ED room at the Broselow Cart on 9/25/2017 at 2:21 PM verified the outdated supplies.

- Observation in the Labor and Delivery room on 9/25/2017 at 12:45 PM revealed the following outdated medical supplies:

2-Sterile Tongue Blades, outdated 2/2015
2-Lubricant, 3gm packages, outdated 11/2012
5-Provent arterial blood gas kits, outdated 6/2017
1-Pediatric Colorimetric CO2 Detector (device used to measure the amount of carbon dioxide that a patient expels), outdated 8/2015
1-Sterile gloves, Size 7, outdated 4/2016
1-Neochild umbilical catheter tray, outdated 7/2015

Outdated medical supplies were confirmed by RN Staff E and Advanced Practice Registered Nurse (APRN) Staff F. All supplies were removed from the room.

- Observation of the crash cart, airway kit, and unsecured cabinet in the Special Care room on 9/25/2017 at 2:45 PM revealed the following outdated medical supplies:
1-20 ml. syringe, outdated 9/2016
3-20 ml syringe, outdated 7/2016
2-60 ml syringe, outdated 7/2016
1-Tongue Depressor, outdated 9/2010
4-Tongue Depressor, outdated 7/2010
3-TB safety syringes, outdated 9/2016
5-Insulin safety syringes, outdated 10/2016
1-IV start kit, outdated 3/2017
2-Clave multi-dose vial access device, outdated 1/2017
3-2x2 Tegaderm dressings, outdated 11/2016
2-Size 8 sterile gloves, outdated 4/2015
2-Size 7 sterile gloves, outdated 6/2015
2-Size 6 ½ sterile gloves, outdated 1/2015
2-Size 7 ½ sterile gloves, outdated 5/2015
1-Open package pediatric electrode pads with 2 pads remaining, outdated 7/11/2016
1-Yankauer suction (suction tip used in medical procedures), outdated 1/2017
2-nasopharyngeal airway, size 28 Fr, outdated 2/2013
2-nasopharyngeal airway, size 24 Fr, outdated 3/2014
2-cuffed ET (ET) (tube used to keep the airway open), size 7.5 mm, outdated 10/2012
1-cuffed ET, size 8.5 mm, outdated 7/2016
1-cuffed ET, size 8.5 mm, outdated 11/2013
2-cuffed ET, size 9 mm, outdated 7/2013
2-cuffed ET, size 7 mm, outdated 2/2013
2-cuffed ET, size 7 mm, outdated 4/2016
2-cuffed ET, size 4.5 mm, outdated 10/2016
1-cuffed ET, size 4 mm, outdated 5/2014
1-cuffed ET, size 4 mm, outdated 7/2011
2-cuffed ET, size 2.5 mm, outdated 4/2014
1-cuffed ET, size 2 mm, outdated 4/2013
2-cuffed ET, size 8 mm, outdated 10/2012
1-cuffed ET, size 6 mm, outdated 4/2015
1-cuffed ET, size 6.5 mm, outdated 9/2016
1-ET guide, outdated 9/2016
1-Adult Colorimetric CO2 Detector, outdated 7/2016

Outdated medical supplies were confirmed by Pharmacy RN Staff C and removed from the room.

Interview on 9/25/2017 at 3:00 PM with Pharmacy RN Staff C stated s/he is responsible for checking all pharmaceuticals for outdates in all of locations in the hospital, but checking supplies for outdates falls to the individual departments and they are to be reviewed for outdates monthly.

Interview on 9/25/2017 at 3:45 PM with ED RN Supervisor Staff D acknowledged the supplies were outdated and the responsibility for checking medical supply outdates in that room and crash cart were the responsibility of the nursing staff and the supplies are to be checked monthly.


- Observation of two of two floor supply areas on 9/26/2017 at 7:10 AM revealed the following outdated medical supplies:

1-Sensatrac Pad (negative pressure pad used for wound healing), outdated 12/2016
1-Sensatrac Pad, outdated 2/2017
1-Wound vac canister (wound vac healing reservoir), outdated 2/2016
1-Wound vac canister, outdated 9/2015

Interview on 9/26/2017 at 7:30 AM of RN Staff H acknowledged the outdated supplies.


- Observation of one of one central supply rooms on 9/26/2017 at 3:00 PM revealed the following outdated supplies:

33-Barrrier Cream Cloth, outdated 2/2/2017
6-Blake Silicone Drain (drain with 4 channels used in surgery), outdated 6/2016
7-Dura Prep Surgical Solution Sponge (surgical prep sponge), outdated 2/2017


Interview of Materials Management Staff QQ on 9/26/2017 at 3:40 PM acknowledged the outdated supplies and removed them from the stock supply. S/he stated he has not been working very long as the materials manager and there is a problem with tracking all of the hospital supplies for outdates. S/he would like to initiate a computerized tracking system.

Policy titled "Storage and Handling of Sterile Supplies" directed, ...store disposable supplies with the nearest outdate to the front or top, using oldest dated supplies first...outdates are checked monthly.


- Observation on 9/26/2017 at 3:08 PM in the CT room of radiology revealed the following outdated supplies in the crash cart:

4 - Lubricating jelly, outdated 12/2014
Interview with staff X on 9/26/2017 at 3:20 PM confirmed and verified outdates in the CT room of Radiology.


- Observation on 9/26/2017 at 9:43 AM in the in the OR anesthesia cart revealed outdated supplies which included:

1 - 4.5 mm Tracheostomy tube (a breathing tube placed through a hole directly into your windpipe to help you breathe), outdated 10/2016
2 - 8.5 mm Tracheostomy tubes, outdated 1/2016

Interview with Staff AA on 9/26/2017 at 9:50 confirmed and verified outdates in the OR room.


- Observation on 9/26/2017 at 9:58 AM in the OR room in the storage cabinets and shelves revealed outdated supplies which included:

1 - 12/13.5/15 "fixed wired" used to dilate (stretch) the esophagus, outdated 01/2015
1 - 12/13.5/15 "fixed wired" used to dilate (stretch) the esophagus, outdated 012/2015
1 - 10/11/12 "fixed wired" used to dilate esophagus, outdated 06/2015
1 - 10/11/12 "fixed wired" used to dilate esophagus, outdated 10/2015
1 - 15/16.5/18 "fixed wired" used to dilate esophagus, outdated 01/2015
1 - 18/19/20 "fixed wired" used to dilate esophagus, outdated 09/2015

Interview with Staff L on 9/26/2017 at 10:10 confirmed and verified outdates in the OR room.


- Observation in the Pre-Operation (Pre/Op) room on 9/26/2017 at 7:44 AM revealed the RN Staff K using a stethoscope on patient #20, returning it to a drawer and failing to clean if after use.

RN Staff K interviewed in the surgical hallway on 9/26/2017 at 11:15 AM verified s/he failed to clean the stethoscope after patient use.


-Observation in Patient Room #7 on 9/26/2017 at 8:10 AM of RN Staff H revealed s/he was obtaining Patient #3's pulse oximetry reading using a multi patient use device. After obtaining reading s/he laid the device on the top of the computer on wheels (COW) without cleaning the device.

Interview of RN Staff H on 9/26/2017 at 8:20 am confirmed s/he did not clean the device before laying it down, but normally "I clean all multi patient use devices after each use."


Policy titled "Cleaning/Disinfecting All Equipment Coming In Contact With Patient/Resident" directed, ...immediately after use, all equipment used for patient/resident care or equipment coming in contact with the patient/resident, is to be wiped down with current hospital grade, EPA approved cleaning solution or towelette/wipe.


- Observation at the entrance to the Dirty Room used to clean endoscopy scopes on 9/26/2017 at 9:31 AM revealed Surgical Tech Staff N dropping a clean glove on the floor, picking it up off the floor, and putting the glove on to use for the cleaning of the colonoscope.

Interview of Tech Staff N in the Dirty Room used to clean the colonoscopes on 9/26/2017 at 9:31 AM verified s/he failed to discard the dirty glove and apply a clean glove prior to cleaning the colonoscope.

Policy titled "Hand Hygiene Hand Washing or Use of Alcohol Based Hand Rubs" directed, ...hand hygiene is the single most important means of preventing the health care worker from transmitting infection to patients and themselves. Hand hygiene is indicated following contact with patients/residents and contaminated or possibly contaminated items.


- Observation of the Procedure Room terminal cleaning on 9/26/2017 at 10:23 AM revealed Tech Staff M using a clean rag on the small metal surgical table and wiping the bottom portion allowing the clean rag to be wiped on the dirty procedure floor, and allowing the electrocardiography (EKG) lines and blood pressure lines and cuff to fall on the dirty floor using the same rag to clean/disinfect them. Tech Staff M continued to clean a total of 13 pieces of procedure equipment with the same dirty rag that touched the floor.

Interview of Tech Staff M outside of the Procedure room on 9/26/2017 at 10:51 AM verified s/he used the same dirty rag to clean the 13 pieces of procedure room equipment.

Interview of RN Staff T in the surgical area on 9/26/2017 at 10:57 AM clarified the cleaning rags should not touch the floor when cleaning the procedure room equipment, and should have been changed to a new rag when continuing to clean/disinfect other equipment.

Policy titled "Environmental cleaning" directed, ...cleaning should progress from the cleanest to dirtiest areas of the floor.


- Observation of Special Care room on 9/25/2017 at 2:45 PM revealed a hopper in the room without splash guards to prevent water spray back when flushed and no PPE was available in the room.

Interview of Pharmacy RN Staff C at 3:00 PM confirmed the absence of both the hopper splash guard and availability of PPE in the room.


- Observation in the Laboratory on 9/25/2017 at 4:45 PM revealed the absence of PPE in the area.

Interview of Lab Staff G confirmed there was no PPE in the area and "I don't remember that we have ever had any PPE."

Policy titled "Personal Protective Equipment (PPE), #1-10 directed ...The employer shall ensure that appropriate PPE in the appropriate sizes is readily accessible at the worksite. PPE should be located close to the point of use.


- Observation in the Special Care room revealed miscellaneous items stored under the sink.

Interview of Pharmacy RN Staff C on 9/25/2017 at 3:00 PM acknowledged and removed the items from under the sink.

The CAH provided no policy regarding storage of items under the sinks.


- Observation in outpatient room for colonoscopy procedure (a long, flexible, tubular instrument about 1/2-inch in diameter transmits an image of the lining of the colon so the doctor can examine it for any abnormalities) on 9/26/2017 at 7:40 AM revealed RN Staff K failed to perform hand hygiene after assessing patient head-to-toe. Also, RN Staff K failed to disinfect the patient's IV connection loop before initiating Intravenous (IV) fluids.

Interview with RN Staff K on 9/26/2017 at 11:00 AM regarding the lack of hand hygiene and disinfection with alcohol to cleanse the connection tubing to IV fluids, Staff K acknowledged "there is always room for improvement".

The CAH's policy titled "Hand Hygiene" from their Infection Control department stated, hand hygiene is the single most important means of preventing the health care worker from transmitting infection to patients and themselves.

According to the Centers for Disease Control (CDC): Parenteral medications should be accessed in an aseptic manner. This includes ...Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.



- Observation on 9/25/2017 at 1:25 PM revealed 3/3 cloth covered chairs in the waiting area of cardiac rehabilitation.

Interview on 9/25/2017 at 1:25 PM with staff member AA confirmed that these seats were uncleanable. 'They have been shampooed" Staff AA is uncertain of date last cleaned.

The prevention and reduction of healthcare-associated infections is a top priority for the U.S. Department of Health and Human Services (HHS).Health care-associated infections (HAIs) are infections people get while they are receiving health care for another condition. HAIs can be caused by bacteria, fungi, viruses, or other, less common pathogens. Continued compliance with existing environmental infection control measures will decrease the risk of health-care associated infections among patients, especially the immunocompromised, and health-care workers.


- Observation on 9/25/21017 at 2:00 PM in the dietary department revealed 2/2 unknown non-dietary staff in the food preparation area without a hairnet.

Interview on 9/27/2017 at 3:00 PM with staff member CC, Hairnets are required in the kitchen.

The CAH policy titled "Foodservice Personal Hygiene" regarding Hair Care directed staff, wearing hair net or cap covering all hair is mandatory.

Based on staff interview, record, and document review the Critical Access Hospital (CAH) failed to ensure an accurate record was maintained to include a discharge summary for 1 of 30 records reviewed (Patient #15). Failure to complete a discharge summary puts all patients at risk for receiving care that is unsafe and inaccurate resulting in harm, and poor outcomes.

Findings include:

- Record review in the conference room on 9/27/2017 revealed Patient #15's record lacked documentation of a discharge summary.

Administration Staff S interviewed in the conference room on 9/27/2017 verified the record for Patient #15 failed to have a discharge summary.

The document titled "Medical Staff Rules and Regulations" directed, ...every record shall include...discharge summary with outcome of hospitalization."

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to perform an annual Quality Assessment and Performance Improvement (QAPI) program evaluation for the years 2012 through 2017. Failure to perform an annual evaluation of all elements of services provided, failure to evaluate current practice against the results, and updating policies and procedures based on the quality results puts all patients at risk of substandard care.

Findings Include:

Interview on 9/27/2017 at 9:00 AM, Chief Executive Officer (CEO) Staff R verified the QAPI program review had not been occurring annually. S/he further stated the quality information is collected by each department but the formalization of a quality program has not been a focus of the CAH. The data collected by each facility department is to be presented to the Board quarterly. The current focus has been a facility review of all written policies with updating and deletion of obsolete policies and providing computerized availability to all facility staff. The completion goal for the facility is the end of 2017.

- Document review on 9/26/2017 at 4:00 PM revealed the most recent QAPI program evaluation was performed in 2012.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, December 13, 2016," committee report as follows: Tissue/Surgical Case Review Committee: None; Pharmacy and Therapeutics Committee: None; Perinatal Committee: None; Risk Management Committee: None; Infection Control Committee: None; Safety Committee: None; Physician Peer Review Committee: None; EMS: None; LTC: None; Education or Patient Care Studies: None.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, April 26, 2017," committee report as follows: Pharmacy and Therapeutics Committee: P & T Agenda-see attached- Ferumoxytol (Feraheme) IV Infusion Policy: Was reviewed and approved by the Medical Staff-Restocking Warm Fluids Policy: Was reviewed and approved by the Medical Staff; Perinatal Committee: None; Risk Management Committee: None; Ems: None; LTC: None; Education or Patient Care Studies: None.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, August 22, 2017," committee report as follows: Pharmacy and Therapeutics Committee: Nursing Home Review ...-Medication Shortages ...-Medication Errors & Recalls ...-Formulary Review ...-Policy Review ...-ER Take Home Packs list and Updates ...-Work In Progress ...; Perinatal Committee: None; Risk Management Committee: None; EMS: None; LTC: None; Education or Patient Care Studies: None.

The CAH failed to produce a policy for the development and review of the annual quality program.

Based on staff interview and document review, the Critical Access Hospital (CAH) failed to perform a continuous assessment of the patient care services and outcomes of care. Failure to continuously monitor patient care services and outcomes places all patients at risk of poor quality of care, unsafe services, and poor health care outcomes.

Findings Include:

Interview on 9/27/2017 at 9:00 AM, Chief Executive Officer (CEO) Staff R verified the Quality Assurrance and Performance Improvement (QAPI) program has not been reviewed annually. S/he further stated the quality information is collected by each department but the formalization of a quality program has not been a focus of the CAH. The data collected by each facility department is to be presented to the Board quarterly. The current focus has been a facility review of all written policies with updating and deletion of obsolete policies and providing computerized availability to all facility staff. The completion goal for the facility is the end of 2017.

- Document review on 9/26/2017 at 4:00 PM revealed the most recent QAPI program evaluation was performed in 2012.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, December 13, 2016," committee report as follows: Tissue/Surgical Case Review Committee: None; Pharmacy and Therapeutics Committee: None; Perinatal Committee: None; Risk Management Committee: None; Infection Control Committee: None; Safety Committee: None; Physician Peer Review Committee: None; EMS: None; LTC: None; Education or Patient Care Studies: None.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, April 26, 2017," committee report as follows: Pharmacy and Therapeutics Committee: P & T Agenda-see attached- Ferumoxytol (Feraheme) IV Infusion Policy: Was reviewed and approved by the Medical Staff-Restocking Warm Fluids Policy: Was reviewed and approved by the Medical Staff; Perinatal Committee: None; Risk Management Committee: None; Ems: None; LTC: None; Education or Patient Care Studies: None.

- Document review on 9/26/2017 at 4:00 PM revealed document titled "Smith County Memorial Hospital Quality Assurance Meeting, August 22, 2017," committee report as follows: Pharmacy and Therapeutics Committee: Nursing Home Review ...-Medication Shortages ...-Medication Errors & Recalls ...-Formulary Review ...-Policy Review ...-ER Take Home Packs list and Updates ...-Work In Progress ...; Perinatal Committee: None; Risk Management Committee: None; EMS: None; LTC: None; Education or Patient Care Studies: None.

- Document titled "Medical Staff Bylaws" reviewed on 9/27/2017 at 10:00 AM directed ...Quality Assessment and Performance Improvement Committee: ... (ii) Quality Assessment and Performance Improvement Activities. The committee shall be responsible for assuring the implementation of a planned and systematic process for monitoring and evaluating the quality of the care and treatment of patients served and the clinical performance of all individuals with Clinical Privileges.

Based on staff interview, record, policy and procedure review the Critical Access Hospital (CAH) failed to ensure an accurate and complete comprehensive assessment for 5 of 30 records reviewed (Swing Bed Patients # 1, 2, 3, 4, and 5). Failure to complete a comprehensive assessment puts all patients at risk for receiving care, medications, and treatment that is lacking in completeness for all areas of patient needs and care.

Findings include:

- Record review in the conference room on 9/26/2017 revealed Patient #1's medical record failed to include documentation of the patient participating in activities and receiving social work visits.

- Record review in the conference room on 9/26/2017 revealed Patient #2's, #3's, #4's, and #5's medical records failed to include documentation of vision and dental assessments.

Administration Staff S interviewed in the conference room on 9/26/2017 at 4:29 PM verified the records for Patients #2 - #5 failed to include documentation of a vision and dental assessment. Staff A explained the facility does not require a vision and dental assessment as part of the swing bed comprehensive assessment.

Administration Staff S interviewed in the conference room on 9/26/17 at 4:29 PM verified the record for patient #1 failed to include documentation of activities and social worker visits.


Policy titled "Comprehensive Admission Assessment" directed, ...a description of the patient's sensory and physical impairments ...a description of the patient's dental condition ...a description of the patient's potential for engaging in activities.

Policy titled "Activities and Recreation" directed, ...the selection of activities for an individual patient will be based on the comprehensive assessment of each patient and the periodic reassessment during hospitalization.

Policy titled "Social Services" directed, ...it is important that the Social Service functions to meet the medically-related and discharge planning needs for Swing Bed patients exist to allow them to attain or maintain the highest practicable level pf physical, mental, and psychosocial well-being.

Policy titled "Multidisciplinary Plan of Care" directed, ...the multidisciplinary plan of care is the responsibility of the multidisciplinary team. The initial plan will be developed within 72 hours of admission and reflect all current needs of the patient and the team-based plan for addressing those need ...the team will meet at least weekly to review the plan and patient progress within the plan ...the patient and family members will be offered the opportunity to participate in these multidisciplinary meetings.

Based on staff interview, record, policy and procedure review the Critical Access Hospital (CAH) failed to ensure a comprehensive care plan was completed for 1 of 30 records reviewed (Swing Bed Patient #1). Failure to ensure a comprehensive care plan was completed puts all patients at risk for failing to receive care, treatments, and discharge planning for safe and accurate health care outcomes.


Findings include:

- Record review on 9/26/2017 in the conference room revealed Patient # 1 admitted on 9/19/2017 failed lacked documentation of care plan meetings and participation in care plan meetings.

Administration Staff S interviewed in the conference room on 9/26/2017 at 4:29 PM verified the record for Patient #1 failed to include documentation of a care plan meeting since admission.

Policy titled "Multidisciplinary Plan of Care" directed, ...the multidisciplinary plan of care is the responsibility of the multidisciplinary team. The initial plan will be developed within 72 hours of admission and reflect all current needs of the patient and the team-based plan for addressing those need ...the team will meet at least weekly to review the plan and patient progress within the plan ...the patient and family members will be offered the opportunity to participate in these multidisciplinary meetings.