HospitalInspections.org

Based on review of policies and procedures, documents, observations, and interviews, the facility failed to ensure the daily monitoring of the hydrocollator's temperature prior to patient use as evidenced by lack of documentation on temperature logs.

Findings include:

Policy titled "Hot Packs, Reviewed 02/25/2020" revealed: "...The hydrocollator moist heating pack usually consists of a canvas case filled with bentonite...The packs are stored in a thermostatically controlled cabinet in water at a temperature of 71.1°C to 79.4° (159.8°F - 174.2°F)...."

Policy was requested on 09/23/2021, regarding the maintenance/temperature checks for the hydrocollator and none was provided.

Document titled "Task Overview, July 2021" revealed the temperature checks were documented as in compliance 14 of 22 times.

Document titled "Hydroculator {sic} Monitoring, July 2021" revealed only 10 dates were listed and 3 of the dates (07/07/2021 (3), 07/08/2021 (2), and 07/29/2021 (2)) had multiple entries for completion of hydrocollator temperature checks. Validation of compliance was completed on 07/09/2021, by Employee #8-Rehabilitation Manager.

Document titled "Task Overview, August 2021" revealed the temperature checks were documented as in compliance 17 of 22 times.

Document titled "Hydroculator {sic} Monitoring, August 2021" revealed only 10 dates were listed and 5 of the dates (08/04/2021 (2), 08/12/2021 (3), 08/18/2021 (2), 08/26/2021 (3), and 08/31/2021 (2)) had multiple entries. Validation of compliance was completed on 08/05/2021, by Employee #8-Rehabilitation Manager.

Document titled "Task Overview, September 2021" received on 09/23/2021, revealed temperature checks were documented as in compliance 10 of 14 times, including the temperature checks for 09/21/2021 and 09/22/2021, were listed as overdue.

Observations on tour conducted on 09/21/2021, revealed that the Rehabilitation Services Department contained a hydrocollator and the cleaning of the hydrocollator was in compliance.

Employee #8-Rehabilitation Manager confirmed during an interview conducted on 09/21/2021, that the documentation for temperature checks of the hydrocollator are not being documented every day.

Employee#1-Director of Quality/Risk confirmed during an interview conducted on 09/23/2021, that Validation means the manager is looking at tasks to ensure staff are performing their quality assurance as directed.

Based on review of policies and procedures, observation, and interviews, it was determined that the Pharmacy failed to remove outdated medications from Departments within the Critical Access Hospital. This poses a potential threat that expired medications could be administered to patients.

Findings include:

Policy titled "Expired Medication Control" revealed "...On a monthly basis, pharmacy staff will inspect, remove, and replace all outdated medications found in preparation, dispensing, and storage areas of the hospital...."

On 09/22/2021, a policy regarding expired supplies was requested; however, none was provided.

Document titled "Current NCCH Floor Plan," signed by Employee #3, the Director of Operations, and dated 09/20/2021 identified the area referred to as the "Specialty Clinic" as part of the CAH's licensed space.

The "Arizona Administrative Code" at R9-10-234. Physical Plant Standards identifies "...A hospital's premises or any part of the hospital premises is not leased to or used by another person...."

An unannounced tour of the Critical Access Hospital (CAH) on 09/22/2021 identified a total of 12 expired medications and/or supplies. Ten expired items were found in the area referred to as the "Specialty Clinic" as follows: one partially used container of 100 UA Reagent strips, expired 09/14/2020; one tube of lubricating gel opened with no date on it; three bottles of aluminum chloride, two expired 08/13/2020, and one with the label torn and no visible date; two 15 mg. bottles of Mastisol expired 09/2020; and, two 1 oz tubes bacitracin zinc, open/used, yet not dated; and, one 1 oz. tube of bacitracin ointment opened/used, yet not dated. There were 2 expired items found in the Emergency Department code cart as follows: one 500 ml. bag of normal saline, expired 08/2021; and, one needle set 15 mm. 15 opened and not dated.

Employee #5 confirmed in an interview on 09/22/2021 that the above listed medications and/or supplies were all expired, and still available for patient use.

Employee #4 confirmed that the "Specialty Clinic" area is not monitored by the CAH staff.

Based on review of policies and procedures, documents and interview, the hospital failed to have the individual in charge of infection control appointed by the medical staff or governing board.

Findings include:

Policy titled "COVID-19 Pandemic Plan" revealed: "...Staff Education...4. Just in time training will be provided as needed for direct clinical care staff by the infection control nurse or other designated qualified...employee ...."

Document titled "Infection Control Plan" revealed: "...Infection Control Coordinator...The Infection Prevention Manager reports to nursing administration...Qualifications...Infection Prevention Manager are met through education, training, and experience with Centers for Disease Control (CDC) guidelines...If a nurse is selected to fill this role, he or she will be encouraged to receive additional training...."

Document titled "Northern Cochise Community Hospital (NCCH), Infection Control Committee Meeting, 06/10/2021" revealed members present included Employee #1 and his/her title was listed as Director of Quality/Risk/Employee Health/Infection Control. The meeting was called to order by Employee #1.

Document titled "Job Description, Infection Control" revealed: "...Essential Functions: Develops and implements infection control plans for NCCH organization, which includes Critical Access Hospital and Rural Health Clinics ...."

Employee #1 Director of Quality/Risk/Infection Control confirmed during an interview conducted on 09/21/2021, that s/he is the infection control person and s/he has not been appointed by medical staff or the governing board. Employee #1 Director of Quality/Risk/Infection Control also confirmed that there was nothing in the medical staff or governing board meeting minutes regarding his/her appointment for the person responsible for infection control.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

§485.625(a)(3)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]
(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements.
Centers for Medicare & Medicaid Services, HHS § 485.625
"CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness plan must include, but not be limited to, the following elements:
(a) Emergency plan. The CAH must develop and maintain an emergency preparedness plan that must be reviewed
and updated at least annually. The plan must do all of the following: ...(3) Address patient population, including, but not limited to, persons atrisk; the type of services the CAH has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans."

Findings include:

Observation during review September 20-23, 2021 revealed .The facility was unable to locate any documentation addressing the needs of the patient population within the current written plan .

Employees #1, #3 and #4 confirmed during the exit conferance that the facility was unable to locate any documentation addressing the needs of the patient population or a delegation of authority within the current written plan .

Based on review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

§485.625(b)(8).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Findings include:

During document review on September 20-23, 2021 it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employee #1, #3 and #4 confirmed during an interview that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.