HospitalInspections.org

The facility failed to follow federal, state, and local laws and regulations defined in 42 CFR 489.24(b) as evidenced by:

Based on observation and interview the facility failed to post a notice conspicuously, in a place likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the Critical Access Hospital (CAH) does not have a doctor of medicine or doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition, as defined in 42 CFR 489.24(b) [the EMTALA definition], at a time when there is no doctor of medicine or doctor of osteopathy present in the CAH.

Findings were:

Observations during a facility tour on the afternoon of 8/10/2021 revealed no posted signs in the dedicated emergency department stating that the Critical Access Hospital does not have a doctor of medicine or doctor of osteopathy present in the hospital 24 hours per day, 7 days a week indicating how the CAH will meet the medical needs of any patient with a medical condition.

The Director of Nurses and Facility Administrator verified these findings.

Based on observation and staff interviews, the facility failed to maintain clean and orderly premises and failed to ensure proper maintenance of the hospital.

Findings were:

Facility Policy entitled Cochran Memorial Hospital Policy & Procedure infection Control Environmental Services last updated July 2016 revealed " ...

C. Emergency Rooms:
1. Upward facing surfaces must be damp cleaned daily using approved disinfectant
solutions. This includes over beds and bedside tables when practical ...
4. High dusting must be performed daily, any area above the shoulder must be properly
dusted using a microfiber cloth/flexible microfiber duster for hard to reach areas.
5. Walls must spot cleaned as needed ...
10. lt also is their responsibility to report any areas that require repair to supervisors or
maintenance staff ..."

During a tour of the facility on the morning of 8/10/2021 with the director of nursing, the following observations were made:

Entrance Hallway:
-The tile flooring was cracked from wall to wall in two areas of the hallway, approximately 10' across. The floor at the cracks was uneven, making thorough cleaning impossible and posing a fall risk to patients and staff.
-There were numerous chips in the tile flooring.
-A hall chair had a tear in the vinyl cover, making it impossible to clean properly
Emergency Room (ER):
-A large drum light above the examining bed had a thick layer of dust.
-Tape was used to post documents/forms on the walls throughout the ER, making cleaning difficult.
All the above findings were confirmed with the director of nursing during the tour of the hospital on the morning of 8/10/21.

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to ensure that drugs were stored in accordance with accepted professional principles, and that outdated, mislabeled, or otherwise unusable drugs were not available for patient use.

Findings were:

During a tour of the facility on the morning of 8/10/2021, the following were available for immediate patient use:

In the emergency room medication storage:
-Multi-dose vial of insulin did not have the date it was opened.
-Premarin Vaginal Cream expired 7/31/2021.
-Dexamethasone Sodium Phosphate did not have the date it was opened.

Review of Cochran Memorial Hospital and ER Policy and Procedure entitled Multidose vial medication dated 6/29/2016 reflected,
"1. Once a multidose vial of medication is open and accessed (e.g. needle punctured) the vial should be dated with a 'beyond Use date'
2. Nurses opening and accessing multidose vials are responsible for placing the 'beyond use date' on the vial. The 'beyond use date' should be 28 days from the date of accessing the medication with a needle, unless the manufacturer specifies a different (shorter or longer) date for the opened vial.
3. Nurses must not use medication with a date that is 'beyond use date'.
4. Medication that is past 'beyond use date' must be discarded"
.
The above findings were confirmed on 8/10/2021 by the Director of Nursing (DON).

Based on interview and record review, the facility filed to have an active facility-wide program for the surveillance, prevention, and control of HAIs and other infectious disease when the facility failed to:

A. have an individual, who is qualified through training, responsible for the infection control and updated infection control policies. Refer to C1204

B. ensure the infection prevention and control program addressed any infection control issues identified by public health authorities when the facility failed to follow the Centers for Disease Control recommendations for screening and masking during the COVID-19 pandemic. This failure could result in the transmission of illness to patients, staff, or visitors resulting in injury or possible death. Refer to C1208

Based on interview and observation, the facility failed to have an individual, who is qualified through training, responsible for the infection control and updated infection control policies.

Findings were:

During an interview on 8/9/2021 at 1:10 pm with the Director of Nursing/Infection Preventionist, staff #13, when asked about Infection control training Staff #13 stated "Thank goodness you are telling me this because I don't know what I'm doing. We did not add any new policies during COVID. I did education but did not document the education." When asked if he followed the CDC recommendations, he stated that he did not. He denied having any infection control training and was unaware of where to look up information on reportable conditions.

Observation on 8/9/2021 at 4:35 pm revealed Staff #13 at the nurse's station with no mask on.

Review of the Director of Nursing's, staff #13, job description, signed 8/17/2020 reflected ...
"Evaluates the education and training needs of personnel and directs development and implementation of in-service programs ...
Is responsible for the overall direction, coordination and evaluation of the hospital floor.
Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws ..."

Review of a signed document, dated 8/10/2021 reflected Staff #13, "Director of Nursing and Infection Preventionist, does not have Infection Control Training." This document was signed by the Facility Administrator and CEO.

Based on observations, record review, and staff interview, the facility failed to ensure the infection prevention and control program addressed any infection control issues identified by public health authorities when the facility failed to follow the Centers for Disease Control recommendations for screening and masking during the COVID-19 pandemic.

Findings were:

Review of the Centers for Disease Control and Prevention (CDC) "updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccinations," updated April 27, 2021 (available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccine.htm) " ...CDC has updated select healthcare infection prevention and control recommendations in response to COVID-19 vaccination, which are summarized in this guidance ...
- Visitors should be screened and restricted from visiting, regardless of their vaccination status, if they have current SARS-CoV-2 infection; symptoms of COVID-19; or prolonged close contact (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection in the prior 14 days or have otherwise met criteria for quarantine ...
- Visitors, regardless of their vaccination status should wear a well-fitting cloth mask, facemask, or respirator (N95 or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators) for source control, except as described in the scenarios below ...
Physical distancing and source control recommendations when both the patient/resident and all of their visitors are fully vaccinated:
-While alone in the patient/resident's room or the designated visitation room, patients/residents and their visitor(s) can choose to have close contact (including touch) and to not wear source control.
-Visitors should wear source control and physically distance from other healthcare personnel and other patients/residents/visitors that are not part of their group at all other times while in the facility.
Physical distancing and source control recommendations when either the patient/resident or any of their visitors are not fully vaccinated:
- The safest approach is for everyone to maintain physical distancing and to wear source control. However, if the patient/resident is fully vaccinated, they can choose to have close contact (including touch) with their unvaccinated visitor(s) while both continue to wear well-fitting source control ...
Healthcare Personnel
-In general, fully vaccinated HCP (healthcare personnel) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. If unvaccinated HCP are present, everyone should wear source control and unvaccinated HCP should physically distance from others ...
Healthcare settings refers to places where healthcare is delivered and includes, but is not limited to, acute care facilities ..."

Observations on 8/9/2021 at 9:15 am revealed the receptionist sitting at the desk with no mask on. No one asked to take surveyors' temperatures or answer any questions related to COVID.

Observation on 8/9/2021 at 2:30 pm revealed two visitors in the hall. None of the visitors had on masks.

Observations on 8/9/2021 at 2:50 pm revealed a yellow isolation cart in the hall between rooms 118 and 120. No isolation signs were observed on the patient door. Three staff were at the nursing station and one was walking in the hall. Two of the four staff were observed not wearing a mask.

Observation on 8/9/2021 at 4:35 pm revealed Staff #13 at the nurse's station with no mask on. Further observation revealed two nurses with no masks on in the patient care area.

During an interview on 8/9/2021 at 1:00 pm Staff #13 revealed that he had not updated the infection control policies related to COVID. He continued that he had done some training back in March of 2020, but he did not have any documentation to support this.

During an interview on 8/9/2021 at 1:10 pm when asked about Infection control training Staff #13 stated "Thank goodness you are telling me this because I don't know what I'm doing. We did not add any new policies during COVID. I did education but did not document the education." When asked if he followed the CDC recommendations, he stated that he did not. He denied having any infection control training and was unaware of where to look up information on reportable conditions.

During an interview on 8/9/2021 at 2:45 pm Staff #5 revealed that a patient with COVID 19 was being admitted for outpatient therapy. The patient was being admitted into room 120. When questioned about the procedure for isolation, she continued that she would use room 118 and the bathroom between rooms 118 and 120 for donning and doffing PPE. Room 118, the room the patient will be in has a negative pressure unit set up.

Review of the "Employee Facemask Policy", dated April 16, 2020 reflected" To ensure the safety of the patients and employees of Cochran Memorial Hospital and Cochran Memorial Clinic, the following facemask policy will be put into effect until deemed unnecessary by the Facility Administrator.
-All medical staff of the Hospital and Clinic are to wear proper PPE that includes and N-95 mask when having direct contact with patients.
-All medical staff of the Hospital and Clinic will be properly trained by their supervisor on face mask use and will be used in the context of a comprehensive, written respiratory protection program that includes fit-testing, training, and medical exams.
-Employees that do not have direct contact with the patients are not required to wear a facemask. If these employees would like to wear a face mask, then they are free to do so. Employees that are not required to wear facemasks should continue to practice social distancing and proper hand and face hygiene.
-Patients, visitors, and vendors that enter the facility will be asked to wear a facemask. This facemask will be provided to the patient by the facility free of charge.
-All hospital employees will continue to be medically screened every morning upon entering the facility." ...

During an interview on 8/9/2021 at 3:30 pm Staff #18 stated that he "couldn't remember exactly when the facility stopped screening and wearing masks. It was when the numbers (of COVID cases) went down and the Governor said we didn't need to wear masks anymore." He continued that "none of the staff had been fit-tested".

The facility was notified on 8/9/2021 at 5:05 pm that there was a possible Immediate Jeopardy at the facility related to infection control. The Director of Nursing/Infection Preventionist, staff #13 does not have any formal training in Infection Control; and the facility failed to follow the CDC recommendations which remain in place for healthcare personnel and visitors in healthcare facilities to continue wearing masks. Staff members #13 and 18 stated that they would be happy to fix what is wrong and would re-instate masking and screening on 8/9/21, the same day. The Facility Administrator was e-mailed the an IJ template covering the identified infection control immediate jeopardy of not having an individual who is qualified through training, responsible for the infection control and updated infection control policies.

Review of a signed document, dated 8/10/2021 reflected Staff #13, "Director of Nursing and Infection Preventionist, does not have Infection Control Training." This document was signed by the Facility Administrator and CEO.