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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on November 14 -15, 2016, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure emergency equipment was properly inspected and maintained, potentially affecting all pediatric patients receiving care in the CAH.

Findings include:

1. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, in a cabinet in the automated external defibrillator (AED) room, an AED was without pediatric defibrillator pads.

2. On 11/15/16 at 9:40 AM, the "AED Check off" sheet was reviewed. Under "Battery/Pads/Initials" it indicated the pad's section of the form was signed off by a staff member on a weekly basis from 10/18/16 to 11/14/16.

3. An interview with the Director of Therapy Department (E #6) was conducted on 11/15/16 at 10:00 AM. E #6 confirmed the AED did not have pediatric defibrillator pads and verbalized "We do provide services to pediatric patients and should have pediatric defibrillator pads available for use." E #6 also indicated the check off sheet was being filled out, but the pediatric defibrillator pads were not included on the check sheet and should be.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a Sample Validation Survey conducted on November 14-15, 2016 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on document review, observation, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure all drugs and biologicals were not expired, potentially affecting all patients receiving care in the CAH.

Findings include:

1. The CAH undated policy "Unusable Medications and Devices" no revision date, was reviewed on 11/15/16 at 1:30 PM. The policy lists under "Definition of Unusable Medications and Devices" the following: "Expired (outdated), recalled, defective, contaminated... Under "Return of Unusable Medications and Devices to the Pharmacy" the policy indicates, "Pharmacy, nursing and other personnel who discover unusable medications and devices shall return them to the pharmacy for proper disposition. Unusable medications and devices shall be handled and disposed of in accordance with this policy."

2. During a tour of the Sleep Study Lab conducted on 11/14/16 at 2:30 PM, in the sleeping rooms, two (2) cans of hand foam sanitizer had expired. One (1) expired on 02/2016 and the other on 05/2016. One (1), 4 fluid ounce bottle of mouthwash had expired on 05/2015.

3. An interview with the Director of Cardiac Rehabilitation (E #5) was conducted on 11/14/16 at 3:00 PM. E #5 confirmed the bottle of mouthwash and hand sanitizer had expired and stated that it should have been removed from the Sleep Study Lab area.

4. During a tour of the medical surgical unit with E#9 (Nurse Manager/Med-Surg) on 11/14/16 at 11:30 AM, in the medication refrigerator one (1) multi dose vial of Succinylcholine 400 mg/20 ml had expired on 11/1/16.

5. During a tour of the surgical department on 11/15/16 with E#8 (Nurse Manager-surgery) at 12:15 PM, in the anesthesia medication room, two (2) bags of lactated ringer's intravenous solution had expired on 10/2016 and one (1) bag of normal saline had expired on 9/2016.

6. Interviews with both E#8 and E#9 were conducted at the time of the tours. E#9 and E#8 agreed the items were unusable and should have been removed from the areas and returned to pharmacy.

A. Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure infection control practices were in place and followed to prevent the transmission of infections, potentially affecting all staff of the CAH, visitors to the CAH, and patients receiving care in the CAH.

Findings include:

1. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, in a cabinet in the automated external defibrillator room, were undated small bottles of ultrasound gel. Next to the bottles was a 1.3 gallon container of ultrasound gel.

2. An interview with the Director of Physical Therapy (E #6) was conducted on 11/15/16 at 10:00 AM. E #6 stated that the large 1.3 gallon ultrasound gel container is marked with an expiration date and when the small bottles are empty they are repeatedly filled with gel from the 1.3 gallon container. E #6 stated that the small bottles are not cleaned prior to being refilled to ensure residual gel is not expired, contaminated or unsuitable for patient use. E #6 also indicated the small bottles are not marked with an expiration date.

3. On 11/15/16 at 1:30 PM, the CAH policy "Unusable Medications and Device" no revision date, was reviewed. Under policy it indicated "Unusable medications and devices shall not be distributed or administered."

4. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, in the Aquatic Room, the "Pool Chemical Log" was not completed as required. Directions on the log required the chlorine to be checked 2 times a day, the PH (acidity) checked once a day, and the alkalinity checked once a week. There was no documentation indicating the chlorine, PH, and alkalinity was checked from 11/10/16 to 11/15/16, as required.

5. During an interview with the Director of Physical Therapy (E #6) on 11/15/16 at 9:45 AM, E #6 indicated the "Pool Chemical Log" was not filled out properly, and verbalized "It should have been." On 11/17/16 at 10:20 AM, E #6 indicated there was no CAH policy related to pool chemical checks.

6. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, in the treatment area, there was a de-humidifier with dried, brown, foreign material on the bottom of the liquid catchments container, and on the washable filter.

7. During an interview with the Director of Physical Therapy (E #6) on 11/15/16 at 9:45 AM, E #6 confirmed the de-humidifier filter and catchment container was dirty and should have been cleaned. E #6 also indicated there was no CAH policy related to the use of the de-humidifier.

8. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, in the treatment area, there was a leg strengthening machine and a stationary peddling machine with torn material on the seating and lying area. The padding was exposed and prevented the machines from being properly cleaned.

9. On 11/17/16 at 2:00 PM, the CAH policy "Cleaning and disinfection of Equipment.....Solutions" implementation date of 10/1/15 was reviewed. Under "Policy" it indicated "Equipment will be cleaned after each use with disinfectant wipes (currently Sani-Cloth Plus). The equipment will be allowed to air dry before use on another patient."

10. During an interview with the Director of Physical Therapy (E #6) on 11/15/16 at 9:45 AM, E #6 confirmed the covering on the two machines was torn and worn allowing the padding to come in contact with patients. E #6 verbalized "We only clean the machines when we think the machines get dirty but we clean the treatment tables after each patient." E #6 also indicated there was no CAH policy related to cleaning the machines.

11. During a tour of the Physical Therapy Department on 11/15/16 at 9:40 AM, on the parallel bars there were "Therabands" attached to the bars.

12. During an interview with E #6 on 11/15/16 at 10:00 AM, E #6 confirmed the "Therabands" were attached to the parallel bars and stated "We use those on multiple patients without being sanitized between patients."

13. During a tour of the Dietary Department, conducted on 11/14/16 at 11:15 AM, on the "three compartment sink" there was an unworkable thermometer in a basket filled with bottles of "QAC QR Test Strips". The instructions on the test strip bottles indicated the water "Sample must be at room temperature (above 75 degrees)". There was no documentation to indicate the temperature of the water, used for sanitizing, was being properly checked.

14. During an interview with the Food Service Director (E #4) on 11/14/16 at 11:30 PM, E #4 confirmed the thermometer was not working and indicated it was used to test the water temperature. E #4 did not know why the water temperature was being checked and was unable to provide documentation that the water temperature was being checked.

B. Based on document review, observation and staff interview, it was determined for 1 of 8 surgical staff (E#10), the CAH failed to ensure policy regarding proper surgical attire was followed to prevent the transmission of infections, potentially affecting all staff of the CAH and patients receiving care in the CAH.

1. The policy adopted from the Association of periOperative Registered Nurses (AORN), Guidelines for perioperative practices, 2016 edition was reviewed on 11/16/16 at 10:00 AM. The policy indicates on page 105 under "Surgical Attire, I.j. Jewelry (e.g., earrings, necklaces bracelets, rings) that cannot be contained or confined within the scrub attire should not be worn. Wearing earrings, watches, and rings was found to increase bacterial counts on skin both when the jewelry is in place and after it is removed."

2. A surgical procedure was observed for Pt #12 on 11/15/16 at approximately 9:00 AM. During the procedure E#10 was wearing a silver toned watch and ring. Neither piece of jewelry was contained in the surgical attire E #10 was wearing.

3. An interview was conducted with E#8 (Nurse Manager-surgery) on 11/16/16 at 9:30 AM. E#8 reported the hospital follows the policies for surgical attire from the AORN guidelines. E#8 had observed E #10 wearing the watch and ring and agreed these should have been removed and stated "Surgical staff are not to wear any jewelry while in the OR (operating room)."

Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure all food items were not expired, potentially affecting all patients, visitors and staff utilizing the food service in the CAH.

Findings include:

1. On 11/15/16 at 1:00 PM the CAH policy "Dating of Supplies", no revision date, was reviewed. Under "8." it indicated "Supplies will be discarded according to normal shelf life, manufactures recommendations, and/or Illinois Department of Public Health guidelines."

2. During a tour of the Dietary Department conducted on 11/14/16 at 11:15 AM, in the food storage room, there were thirteen (13) syrup containers (11 ounce) that had expired in July 2016.

3. An interview with E #4 (food service director) was conducted on 11/14/16 at 11:30 AM. E #4 stated that all the syrup containers had expired and they should have been removed from the food storage room and disposed of properly.

Based on document review and staff interview, it was determined in 1 of 2 (Pt #20) medical record reviewed, where the patient was transferred to another medical facility, the Critical Access Hospital (CAH) failed to ensure the medical record was accurate and complete, potentially affecting all patients receiving care in the CAH.

Findings include:

1. On 11/16/16 at 2:00 PM, the medical record of Pt #20 was reviewed. Pt #20 was admitted on 6/23/16 with diagnoses of shortness of breath, lethargy and complications from multiple sclerosis. On 6/24/16, Pt #20 was transferred by ambulance to another medical facility. Documentation on the "Transfer Authorization" form indicated under "Available Marshall Browning Hospital/other emergency/medical records/X-rays sent with patient", was unmarked. There was no documentation to indicate what medical records were sent with the patient.

2. On 11/16/16 at 2:00 PM, the CAH policy "Transfer and EMTALA", no revision date, was reviewed. Under "Transfer" 9th bullet statement, it indicated "All of the patient's pertinent medical records and copies of all the appropriate diagnostic test results which are reasonably available shall be transferred with the patient."

3. On 11/16/16 at 2:30 PM, an interview with the Chief Clinical Officer (E #1) was conducted. E #1 verbalized Pt #20's medical record did not indicate what records accompanied the patient and should have reflected that on the transfer sheet.