HospitalInspections.org

The Critical Access Hospital (CAH) reported average daily census of .21 patients with a current census of 19 patients, two skilled swing bed patients and 17 intermediate swing bed patients. Based on observation, policy review and staff interview, the CAH failed to ensure supplies commonly used in life-saving procedures were readily available to staff in the emergency room (ER), in the outpatient treatment room, and in one of two emergency carts observed (cart A). The CAH's failure to ensure emergency supplies were available to patients has the potential to cause harm and delays in the emergency care of patients.

Findings include:

- The ER cabinets observed on 5/9/16 between 2:15pm to 4:10pm revealed the following outdated supplies:
1. Three disposable staple removers (an instrument used to remove surgical staples, used to close a surgical wound) with an expiration date of 3/13.
2. Two chest tubes (a tube inserted into the chest cavity to re-inflate the lungs) with an expiration date of 2/12.
3. Four chest drainage kits (a package containing all the necessary equipment to drain fluid from a chest cavity) with an expiration date of 3/13.
4. One lumbar puncture kit (a package containing all necessary equipment to do check the fluid in the spine) with an expiration date of 11/08.
5. One opened Combitube kit (used to maintain an open airway) with an expiration date of 1/14.
6. One container with six empty sterile 1000 milliliter (ml) bottles used to collect fluid when draining fluid from the chest cavity with an expiration date of 6/1/11.
7. Three multi-lumen Central Venous Catheterization kit (used to insert a catheter into a large vein to give medications and fluids) with an expiration date of 8/08.

- The outpatient treatment room observed on 5/9/16 between 2:15pm to 4:10pm revealed the following:
1. One Betadine swab stick package (used to clean the skin before doing a procedure) with an expiration date of 10/13.
2. One Chloraseptic swab stick package (used to clean the skin before doing a procedure) with and expiration date of 8/15.

- The ER emergency cart A observed on 5/9/16 between 2:15pm and 4:10pm revealed the following:
1. Two Carbon Dioxide detectors (an instrument used to measure the carbon dioxide air level the patients breath out) with an expiration date of 2/15.
2. Two Endotracheal tubes (a tube inserted in the patients airway to help them breath) with an expiration date of 4/13.
3. One endotracheal tube with an expiration date of 2/13.
4. One package containing two electrodes (a patch used on the patient ' s chest when they shock the patient's heart) with an expiration date of 11/13.

Registered Nurse staff B interviewed on 5/9/16 at 4:10pm acknowledged the expired unusable supplies and explained they were not aware of the expired supplies.

- The CAH's policy/procedure titled "Commercial Products" reviewed on 5/11/16 at 3:00pm directed, "...All items must be destroyed after reaching their expiration date marked on the manufacturer's packaging ..."

The Critical Access Hospital (CAH) reported average daily census of .21 patients with a current census of 19 patients, two skilled swing bed patients and 17 intermediate swing bed patients. Based on Medical Staff Bylaws reviewed, policy review, and staff interviews the CAH failed to have a system in place to provide either directly or under arrangement blood or blood products needed for its emergency patients on a 24-hour a day basis. The CAH's failure to ensure blood or blood products were available to patients on an emergency basis has the potential to cause harm and delays in the care of these patients.

Findings include:

Administrative Registered Nurse staff A interviewed on 5/9/16 at 10:35am during entrance explained the CAH does not provide blood or blood products to any of their patients. Staff A verified the CAH does not have an arrangement in place for the procurement of blood or blood products or a contact/arrangement in place with another local hospital to accept a patient in transfer in the case blood or blood products were needed.

- The CAH's Emergency Room policy/procedure reviewed on 5/12/16 at 12:30pm directed, "...The Jewell County Hospital does not administer blood or blood products at this facility. The lab will maintain current policy and procedure for addressing the needs of the patients that need this service..."

Administrative Laboratory Director Staff P interviewed on 5/10/16 at 11:00am explained the CAH does not give blood nor have they given blood in the past 17 years and the lab doesn't have a policy addressing the issue.

- The Medical Staff bylaws, rules and regulations reviewed on 5/9/16 at 12:20pm directed, "...Blood transfusions are not performed at Jewell County Hospital".

Administrative Laboratory Director Staff P on 5/12/16 at 2:30pm during the exit conference explained lab had not provided blood banking services since around 1999 following a survey completed by the state laboratory staff.

Based on observation, policy/procedure review, manufacturer's guidelines and staff interview the Critical Access Hospital (CAH) failed to develop an active and comprehensive infection control system which identified and investigated staff practices (Refer to C-278) and failed to ensure that outdated drugs were not available for use (Refer to C-276).

The cumulative effect of the systemic failure of the CAH to develop an active and comprehensive infection control system has the potential for cross contamination and acquisiton of healthcare aquired infections.

The Critical Access Hospital (CAH) reported average daily census of .21 patients with a current census of 19 patients, two skilled swing bed patients and 17 intermediate swing bed patients. Based on observation, policy/procedure review, and staff interview the CAH failed to ensure outdated medications were not available for patient use in one of one Emergency Rooms (ER). The failure of the CAH to ensure outdated medications were not available for patient use has the potential to affect all patients who present to the ER seeking medical care.

Findings include:

- The ER observed on 5/9/16 between 2:15pm to 4:10pm revealed two five milliliter Heparin flush (500 units per milliliter) syringes on the counter with an expiration date of 3/16.

Registered Nurse (RN) staff B interviewed at 4:10pm acknowledged the outdated Heparin flush syringes and explained staff are to check for outdated medications monthly.

- The CAH's policy/procedure titled "Outdated Drugs" reviewed on 5/11/16 at 12:10pm directed, "The night shift nurse shall put outdated drugs in the drug room, and ER on the last date of the month ... "

The Critical Access Hospital (CAH) reported average daily census of .21 patients with a current census of 19 patients, two skilled swing bed patients and 17 intermediate swing bed patients. Based on observations, policy/procedure reviews, manufacturer's guidelines reviews, and staff interviews the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement an infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel. Deficient infection control practices included observations: in the physical therapy department; of five staff performing inappropriate hand hygiene (Certified Nurse's Aide (CNA) Staff H CNA Staff D, Registered Nurse (RN) Staff G, RN Staff E, Laboratory Staff F; of the sterile processing room; of the tub room; of one of two visitor waiting rooms (waiting room A), of one staff starting an intravenous catheter (RN Staff G), and of one cleaning of a discharged patient's room (Housekeeping Staff Q and R). The CAH's failure to identify deficient infection control practices created the potential for healthcare acquired infections.

Findings include:

- Physical Therapy (PT) department observed on 5/10/16 at 2:10pm revealed a hydrocollator (a machine to warm packs in warm water to place on patients). The PT department lacked evidence of when they cleaned the hydrocollator.

Physical therapy staff C interviewed on 5/10/16 at 2:10pm acknowledged they did not have a schedule for cleaning the hydrocollator, but cleaned it about every three weeks and lacked evidence when they last cleaned the machine. Staff C verified they did not know when they last cleaned the machine.

- CNA Staff H observed on 5/10/16 at 9:00am assisting a patient to their room by wheel chair. Staff H entered the patient's room, assisted the patient into their recliner chair, and exited the patient's room. Staff H failed to perform hand hygiene after leaving the patient's room.

- CNA staff D observed on 5/10/16 at 10:12am assisting a patient in their room into their wheel chair. Staff D failed to perform hand hygiene after leaving the patient's room.

- Registered Nurse (RN) staff G observed on 5/10/16 at 1:45pm performed an intravenous (IV) catheter placement (placing a catheter into a vein to give medications or fluids) for patient #14. Staff G placed extra supplies needed for the IV placement on the patient's unprotected over bed table. When finished with the process, staff G gathered the unused supplies and placed them back into the stock supplies thus contaminating the stock supplies. Staff G also failed to perform hand hygiene after leaving the patient's room.

- RN staff E observed on 5/9/16 at 2:13pm observed administering medications to patient #3. Staff E failed to perform hand hygiene after leaving patient #3's room.

- Laboratory staff F observed on 5/10/16 at 10:00am drawing blood from a patient. Staff F failed to perform hand hygiene after removing their gloves and leaving the patient's room.

- The CAH's titled "Hand Hygiene" reviewed on 5/11/16 at 3:00pm directed "...use an alcohol-based hand rubs for routinely decontaminating hands in the following situations, before/after direct contact with patients, before/after contact with inanimate objects in the immediate vicinity of the patient, after removing gloves..."

Administrative staff A interviewed on 5/11/16 at 9:15am explained they do monthly surveillance regarding the appropriate use of the alcohol-based hand rubs and provide one on one education.

- Observation of the sterile processing room on 5/10/16 at 4:15pm revealed a counter with a copy machine on it that they use to make copies of information for the emergency room (ER) patients, an intravenous pump, equipment used for putting casts on patients, a microwave oven that they use to warm up "rice" packs for patients, and hanging from under the cabinet above this counter was a wire with wooden clothes pins on it. Below the window on the floor was an overflowing wastebasket and two empty cardboard boxes. On another counter sat a table top sterilizer, next to it was a two tiered rack covered with towels and "clean" instruments on it. Next to these instruments was a sink with a blue pan in it where they cleaned the instruments, a red square basin propped up against the wall behind the sink, and on the other side of the sink lay "clean" instruments on towels. Also present in the sterile processing room: a large blanket warmer and a free standing shower used for decontaminating persons if they come in contact with chemical spills.

Licensed Practical Nurse (LPN) Staff I discussed the process for sterilizing instruments in an interview on 5/10/16 at 4:10pm and explained all soiled instruments are first cleaned in the scrub sink in the Emergency Department (ED) with an enzymatic cleaner, then brought into the sterile processing room where the instruments are cleaned in the sink with an enzymatic cleaner, rinsed, and placed on the towels to dry. When dry they place the instruments into the "peel pack" (pouches) for sterilization. This process takes place on the counter next to the sink where they clean the instruments. After sterilization of the packaged instruments, they hang them on the wire with the clothes pins to dry and until they read the results of the biological test done for that load of instruments they sterilized. Staff I explained the Rural Health Clinic brings their soiled instruments to the hospital for cleaning and sterilization of the instruments. Staff I cleans the red basin with the enzymatic cleaner (not a disinfectant) lets it dry and places the sterile packaged instruments in it to return to the Rural Health Clinic.

- Review of the sterilizing logs revealed from 1/31/15 to 5/1/16 the CAH sterilized 40 loads of instruments.

- The CAH's policy/procedure titled, "Designated Work Areas In Sterile Processing" reviewed on 5/11/16 at 3:00pm directed, "...Sterile Processing will be divided into two areas, "clean" and "dirty" ...these two areas will be physically divided and the integrity of each area will be maintained. Only clean items will be taken into the processing area and traffic will be strictly controlled..."

- The CAH's policy/procedure titled, "Unloading the Autoclave" reviewed on 5/11/16 at 3:00pm directed, "...remove instrument packs from autoclave and place them on a metal rack (cover rack with 2 bath towels)..."

Administrative staff A interviewed on 5/10/16 at 5:00pm acknowledged the sterile processing room lacked a division between the clean and dirty areas and agreed that the room was easily and frequently accessed by CAH staff.

- The tub room observed on 5/11/16 between 3:35pm to 4:05pm revealed a tub that has a lift to assist patients into the tub. The areas around the water control knobs had a buildup of a black substance around them and water leaking from the controls. The lift had a buildup of white residue. On the window ledge, there were multiple containers of grooming products that were not labeled. The chair that fit in the tub had tears in the foam around the arms of the chair. The air vent in the ceiling of the room had a buildup of dust/debris.

Certified Nurse Aide (CNA) interviewed on 5/11/16 at 3:45pm explained they clean the tub between each patient, and the multiple containers of grooming products are "community" products that they use for any patient.

- The waiting room (Waiting room A) by the entrance of the CAH observed on 5/10/16 at 10:00am revealed a black vinyl covered three cushioned couch with four to five inch tears in the seams exposing the stuffing in the arms of the couch and two and a half to three inch worn areas on the back cushions, rendering the surfaces uncleanable.

Maintenance staff K acknowledged the tears and worn areas in the cushions of the couch and that they were an uncleanable surface.

- Housekeeping staff Q and staff R observed on 5/11/16 from 2:15pm to 3:10pm revealed staff Q and staff R performing the cleaning of a discharged patient room #104. Staff Q and staff R using cloths wet with a solution of the disinfectant Re-Juv-Nal, wiped the bed side stand, bed frame, mattress, and over bed table. The surfaces remained wet from four to six minutes. Not the required 10 minutes per the manufacturer's guidelines. Staff R poured an unmeasured amount of the product Sup-R-Safe into the toilet bowl at 3:00pm and at 3:07pm using a toilet bowl brush swished the inside of the toilet and flushed the toilet.

Housekeeping staff Q and Staff R interviewed on 5/11/16 at 3:10pm acknowledged the surfaces must remain wet for 10 minutes in order to disinfect according to the manufacturer's guidelines and were unaware the surfaces were not wet for the required time. Staff R explained they received instructions to pour the toilet bowl cleaner "Sup-R-Safe" porcelain cleaner in the toilet let it remain for five minutes, then brush and flush the toilet bowl. Staff R did not know if the toilet bowl cleaner was in fact a disinfectant.

- The manufacturer's guidelines for the disinfectant "Re-Juv-Nal" reviewed on 5/12/16 at 8:25M directed "...2oz/gallon dilution, 10minuts contact time..."

- The manufacturer's guidelines for the toilet bowl porcelain cleaner reviewed on 5/12/16 at 9:35am revealed the product to be a cleaner to remove mineral deposits and other stains and not a disinfectant.

Maintenance Staff K interviewed on 5/12/16 at 3:00pm acknowledged they were unaware the toilet bowl cleaner was not a disinfectant. Staff K explained they switched toilet bowl cleaners because of the ease of use according to the manufacturer's representative.