HospitalInspections.org

Based on observation, document review, and staff interview the critical access hospital (CAH) failed to provide for the safety of patients and or staff in one of one Nursing Supply rooms with portable oxygen tanks and failed to ensure a backflow prevention system (airgap) is in place at the point of water connection for one of one prep sinks located in the kitchen and two of two ice machines. This deficient practice has the potential to allow dirty water to reenter the sink contaminating items being prepared in the sink or contminate the ice.

Findings include:

- Nursing Supply Room observed on 5/6/17 at 4:50 PM revealed an unsecured oxygen tank on the floor.

Registered Nurse Staff H interviewed on 5/6/17 at 4:50 PM verified the unsecured oxygen tank on the floor, removed and secured the tank.

- Policy titled "Therapeutic Medical Gas" reviewed on 5/6/17 directed " ...all freestanding cylinders shall be stored in a tack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them ..."


- Kitchen Area observed on 6/5/2017 at 3:00 PM revealed the facility failed to install airgaps at their food preparation sink and ice machines.

Maintenance Staff D interviewed on 6/6/2017 at 12:50 PM confirmed with the local plumber that airgaps were not present at the food preparation sink or either of the ice machines.

- Policy review on 6/6/2017 revealed the facility failed to provide a policy directing staff to ensure airgaps were installed at ice machines and food preparation sinks.


The FDA Food Code 2009 read in part: 5-202.13 Backflow Prevention, Air Gap.
An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, document review, staff interview the critical access hospital (CAH) failed to ensure that all medications are stored securely in two of two Outpatient Clinic medication storage areas (Therapy Room, and Sample Medication Room) This deficient practice has the potential to allow patient and staff unrestricted access to medications that could cause harm or death. The facility failed to ensure outdated medications were disposed of properly in one of one Physical Therapy areas. This deficient practice has the potential to expose patients to ineffective medications.

Findings include:

- Outpatient Clinic's Therapy Room observed on 6/5/2017 at 4:00 PM revealed the door to be open and the room unattended. An unlocked upper cabinet located to the left of the sink contained vials of stock medication. Two small and unsecured refrigerators one stacked on top of the other revealed vials of stored medications. One tall and unsecured refrigerator contained vials of stored medications.

Registered Nurse Staff F interviewed on 6/5/2017 at 4:20 PM stated, "We leave them (the cabinets) open all day because we are in and out of here so much". Staff F indicated they were not aware they needed to secure medications during business hours.


- Outpatient Clinic's Sample Medication Room observed on 6/5/2017 between 4:20 PM and 4:30 PM revealed an open door with multiple shelves of medication samples stored inside the room. The nurse's station directly in front of the Sample Medication Room was observed to be unattended while the door remained open.

Registered Nurse Staff F interviewed on 6/5/2017 at 4:30 PM revealed the door has a badge reader already installed.

- Policy titled "Drug Storage and Stability" reviewed on 6/6/2017 at 8:00 AM directed " ... Nursing medications shall be kept in a secure area and access restricted to designated medication nurses ..."


- Physical therapy Room observed on 6/5/17 at 11:32 AM revealed a drawer with a small plastic container of acetic acid (vinegar is used as a medication to treat a number of conditions) with an expiration date of 2/23/12.

Physical Therapist Staff G interviewed on 6/5/17 at 11:32 AM verified the expired container of acetic acid and discarded it immediately.

- Policy titled "Drugs Quality Program" reviewed on 6/7/2017 at 8:30 AM directed " ...The pharmacy inventory is inspected on a regular basis to remove outdated or otherwise defective drug products from the pharmacy inventory. This inspection will include any drug items located outside the pharmacy (e.g. Pyxis machine, crash carts,) ..."

Based on observation, interview, document and policy and procedure review the critical access hospital (CAH) failed to ensure a sanitary environment to avoid sources and transmission of infections and communicable diseases. Surgical bouffant hair coverings (a hair covering worn for medical procedures and surgeries) failed to cover side and back of neck hair in 2 of 5 personnel (Surgical Staff J and Physician Staff K) observed in surgery. One of seven sterile tracheostomy tubes (a tube inserted into the windpipe to keep the airway open) was removed from the sterile packaging and laying in a drawer in the medication cart located in the operating room. A glucometer (a medical device used to test blood sugars) was dropped on the floor during a procedure and continued to be used for patient care. One of one foam boards used in physical therapy contained multiple cracks on both sides. One of fourteen outpatient rooms (room #14) contained a pillow and exam paper under a sink. One of one Paraffin Devices (a warm oil-based wax used to provide relief to hands, feet and sore joints and muscles) failed to be regularly cleaned. One of one hydrocollator (a cloth heating pad used for therapy treatments) failed to be regularly cleaned. One of one cold pack units (a unit with cold packs used for therapy) failed to be regularly cleaned. The facility failed to ensure chairs had a cleanable surface for 1 of 1 chairs in the bariatric room, 3 of 3 chairs in the emergency department and 5 of 5 chairs in the therapy room. Terminal cleaning of the operating room failed to separate clean from dirty throughout the cleaning process for one of one operating rooms. Failure of the facility to ensure a sanitary environment puts all patients at risk for care below the state and federal standards for infection control to protect them from infections, blood borne pathogens and communicable diseases.

Findings include:

- Observation on 6/6/17 at 11:50 AM revealed Surgical Staff J and Physician Staff K failed to cover side and back of neck hair with a surgical bouffant during a medical procedure.

Interview on 6/6/17 at 12:32 PM, Surgical Staff J verified the surgical bouffant failed to cover all the hair on the sides and neck during surgery.

- Policy and Procedure review on 6/6/17 revealed policy "Surgical Attire" states ...surgical hats should cover head and facial hair to include sideburns and necklines.



- Observation on 6/6/17 at 12:37 PM revealed one sterile tracheostomy tube out of the package and laying in one of the drawers to the medication cart in the operating room.

Interview on 6/6/17 at 12:37 PM, Surgical Staff L verified the tracheostomy tube opened and exposed in the medication cart in the operating room and disposed of it immediately.

- Policy and Procedure review on 6/6/17 revealed policy "Commercially Prepared Sterile Items" states ...all items prepared commercially that are clearly marked STERILE are considered sterile unless: ...the item is opened.



- Observation on 6/5/17 at 4:50 PM revealed Registered Nurse (RN) Staff I performing a blood sugar check on patient #16. Staff I dropped the glucometer on the floor, picked it up and pricked the patients finger obtaining a blood sample onto the glucometer test strip.

Interview on 6/5/17 at 4:56 PM, RN Staff I verified s/he used a "dirty" glucometer to test patient #16's blood sugar. Staff I stated s/he should have stopped and cleaned it prior to the procedure.

- Policy and Procedure review on 5/7/16 revealed policy "One Touch Ultra 2 Blood Glucose Meter" states ...always keep your meter and lancing device clean.



- Observation on 6/5/17 at 11:37 AM revealed a foam board in the physical therapy room used for patients to stand on to perform therapy had multiple cracks on both sides rendering the surface non-cleanable.

Interview on 6/5/17 at 11:37 AM, Physical Therapist Staff M verified the multiple cracks on the foam board and discarded it immediately.

- Policy and Procedure review on 6/7/17 revealed policy "Use, Care and Cleaning of Department Equipment" states ...to provide equipment which is safe, clean, and meets performance expectations ...equipment should be operated, maintained, and stored in a manner that ensures safe and efficient operation.



- Observation on 6/5/17 at 3:45 PM revealed a pillow and exam table paper stored under the sink in outpatient clinic exam room #14.

Interview on 6/5/17 at 3:50 PM, RN Staff F acknowledged the pillow and paper was stored under the sink.

- Policy and Procedure review on 6/6/17 revealed the facility failed to provide a policy directing staff not to store items under the sink.



- Observation on 6/5/17 revealed the cleaning task list for the hydrocollator showed the facility failed to perform the monthly cleaning for 3 of the last 5 months (February, April and June), documentation of weekly temperatures for the hydrocollator taken in 14 of the last 20 weeks and defrosting the cold pack machine monthly or as needed for the last 5 months (January thru May 2017). The cold pack machine revealed large amounts of ice build-up. The Paraffin machine had a dirty build up on the inside bottom.

Interview on 6/5/17 at 1:12 PM, Therapy Tech Staff E verified the cleaning schedule for the hydrocollator and cold pack machine failed to be completed each scheduled time and the temperature for the hydrocollator failed to be documented and taken timely. Staff E stated the facility failed to show proof of a cleaning log for the paraffin machine and s/he is not aware of when it was last cleaned.

- Policy and Procedure review on 6/5/17 revealed policy "Hydrocollator Steam Pack" states ...the unit should be drained and cleaned at least once a month ...temperature of the unit is checked weekly.

- Policy and Procedure review on 6/7/17 revealed policy "Cleaning Procedures" states Interior to be cleaned with hdqC2, exterior with stainless steel polish as needed.

- Policy and Procedure review on 6/5/17 revealed the policy "Cleaning Procedures" states ...Cold-Pac machine to be defrosted monthly, and cleaned with hdqC2. Exterior cabinet to be polished with stainless steel cleaner as needed".

- Policy and Procedure review on 6/5/17 revealed policy "Paraffin Bath" failed to provide documentation for cleaning the Paraffin machine.



- Observation on 6/5/17 at 10:15 AM revealed the bariatric room with a non-cleanable cloth covered recliner.

Interview on 6/5/17 at 5:00 PM, Director of Nursing Staff B agreed the blue recliner is non-cleanable and should have been removed instead of place in a room for storage.

- Observation on 6/5/17 at 3:15 in the emergency department revealed three wooden chairs with non-cleanable cloth covered seat bottoms.

- Observation on 6/5/17 revealed the therapy department with non-cleanable cloth covered chairs.

Interview on 6/5/17 at 11:37 AM, Therapist Staff M verified the 5 cloths chairs as having a non-cleanable surface.

- Document review on 6/6/17 revealed document "Environmental Services" states ...spray chair down with a hospital grade cleaner (we use Clorox Bleach Spray). Let it set for a few minutes (or Kill time) ...wipe down the chair starting at the top and work your way down. Watching for any repairs needed, continue wiping down the arms, seat and legs of the chairs ...if you find a stain remove the chair from the area and take it to environmental service for further scrubbing. When the chair is completely dry, take it back to its original location.



- Observation on 6/6/17 at 2:00 PM revealed the terminal cleaning of the operating room (OR). Licensed Practical Nurse (LPN) Staff L dropped the clean cloth used to disinfect the surgical equipment on the floor after cleaning the 3rd piece of equipment. Staff L continued to clean all 17 pieces of surgical equipment with the "dirty" cleaning cloth. Staff L also cleaned all the wheels on all 17 pieces of equipment allowing the "clean" cloth to swipe across the dirty floor. Housekeeping Staff N picked up two dirty items from the OR floor with his/her gloves and then proceeded to move clean surgical equipment with the dirty gloves.

Interview on 6/6/17 at 2:35 PM, LPN Staff L verified s/he failed to ensure a clean cloth was used to disinfect all 17 pieces of the surgical equipment and the clean cloth came into contact with the dirty floor throughout the terminal cleaning.

Interview on 6/6/17 at 3:12 PM, Housekeeping Staff N verified s/he failed to change gloves after touching the dirty floor and then touching and moving the cleaned surgical equipment.

- Policy and Procedure review on 6/6/17 revealed policy "Operating Room Environment Sanitation" states ...patients will be provided with a safe, clean environment free of dust and organic debris ...operating staff will be responsible for the following: use of universal standards when handling contaminated items.

Based on interview, record review and document review the critical access hospital (CAH) failed to ensure the History and Physical (H&P) was authenticated within 48 hours after admission for 1 of 20 records reviewed (patient #12). Failure to authenticate the H&P within 48 hours after admission puts all patients at risk for receiving medications, treatments and care that is unsafe with the potential of causing harm.

Findings include:

- Record review on 6/6/17 revealed the H&P for patient was completed on 4/4/17 for services provided on 6/6/17. The physician Staff K authenticated the H&P on 6/6/17, 63 days after the H&P was completed.

Interview on 6/6/17 at 5:05 PM, Staff C verified the H&P was completed on 4/4/17 and authenticated on 6/6/17.

Document review on 6/6/17 directed "...a complete history and physical examination shall be recorded within 24 hours of admission. This report must include the chief complaint, details of the present illness, all relevant past medical, social and family history, the patient's emotional, behavioral and social status when appropriate, and all pertinent finding resulting from a comprehensive, current assessment of all body systems. If a history and physical examination report is not recorded within 24 hours following admission, the physician/practitioner will be notified that the report is delinquent. If the report in question is not recorded within the next 24 hours, the Administrator will contact the physician/practitioner to discuss necessary action ...the medical record is complete when the required contents are assembled and authenticated. This will include the history and physical ...the medical record shall be completed within 30 days of discharge".