HospitalInspections.org

The Critical Access Hospital ' s (CAH) reported an average daily census of 9 patients and provided on site dietary services to an average of 9 patients and 78 of direct or contract employees. Based on observation, document review and staff interview the hospital failed to follow the CAH ' s environmental policies to identify areas in need of repair and cleaning in the dietary department. The failure to follow policy resulted in an unsanitary and unsafe dietary department environment.

The cumulative effect of the failure to follow environmental rounding policies to identify, evaluate and make corrective actions, and to maintain a sanitary dietary environment created the potential to adversely affect the health and safety of all patients and staff at the hospital.


Findings include:

- The CAH failed to ensure maintenance or dietary staff completed environmental rounds in the dietary department to identify areas in need of repair, failed to ensure the staff developed action plans to correct areas in need of repair to ensure a safe clean environment for patient services. See further evidence at C- 221, 42 CFR 485.635(a).


221
The Critical Access Hospital (CAH) provided dietary services as a direct service for an average of 9 patients. The four maintenance staff members (staff E, F, and H) and dietary manager staff D failed to follow accepted standards of practice in the dietary department to maintain dietary equipment to ensure a safe and sanitary dietary department.

Findings include:

- Tour of the dietary department located in the hospital ' s basement on 1/8/13 at 8:15am with dietary manager staff D and environmental supervisor staff F, revealed the following areas in need of repair:

1. Dry storage area #1 contained three industrial stainless steel racks with boxed food and bagged pasta stored on the shelves. The ceiling above the food storage shelves had an " L " shaped raised and rough area of jagged white crystal like growth/stain hanging ½ inch from the ceiling which extended five feet from the right corner of the room on to the back wall, then two feet along the ceiling of the left wall.

2. Dry store area#2 contained four industrial stainless steel racks with boxed food and canned food on the shelves. Observation the back wall revealed a white plastic gutter (formed to make a holding tray) hanging from an 8 foot insulated white pipe. The plastic gutter had holes drilled in the sides with wires inserted to hold the gutter to an 8 foot white pipe. The pipe had a thick white insulation covering with dark fuzzy, round spots that extended the length of the pipe. Maintenance Manger staff E on 1/8/13 at 10:00am reported they placed the gutter under the pipe to catch condensation/moisture from the pipe.

3. Dietary chemical closet adjacent to #1 and #2 ' s storage areas contained a 2-gallon plastic bucket wired to a pipe that extended the length of the (50-foot hallway). The chemical closet also contained a 2-gallon ice cream container and 2-gallon hardware store bucket suspended from a pipe with wire. The bucket has a dry dark buildup covering the bottom of the container.

4. The hallway outside the hospital ' s public/staff dining room had a 2 foot by 2 foot ceiling tile with a 6-inch dark brown stain outlined by a raised fuzzy black substance that looked like mold.

5. The public/staff dining room ' s ceiling had two- 2 foot by 4 foot ceiling tiles with dark brown stains. Stain #1 measured 8 inches by 6 inches with a raised fuzzy black mold like substance. The second dark brown stain measured 4 inches in circumference.

6. The public/staff dining room had a 2-foot by 4-foot plastic vent tile with one-inch open squares. The vent had a red sheetrock mud tray suspended directly over a dining room table.

7. Storage area #3 was a 16-foot by 12-foot room used for miscellaneous storage (not food) and had a suspended ceiling with 4-foot by 2-foot tiles. The ceiling had two tiles with dark brown stains. Storage room #3 ' s ceiling had dark black spots of mold like substance, which extended the length of the wall.

8. The dietary manager ' s office exterior wall had a 3-foot by 2-foot window located below ground, with an exterior window well. The wall below the window had a 3 X 2-foot irregular half moon shaped area of bubbled wall surface. Pressure applied to the raised, bubbled area, created a loud audible crunchy sound.

Maintenance staff H at 1:00pm, and environmental supervisor staff F opened the surface of the bubbled wall to reveal a white fuzzy unknown substance. Environmental supervisor staff F indicated the areas were mold based, but would need to consult with an expert to obtain a final report.

Maintenance director staff E interviewed on 1/8/13 at 10:00am reported they had been employed by the hospital for the passed 20 years and were responsible for hanging the various buckets, sheetrock mud trays and made the white gutter tray. Maintenance director staff E stated the pipes in the basement have a condensation problem in the summer which causes the pipes to sweat. Maintenance director staff E stated the various devices (buckets and guttering) catch the sweat and drips from the pipes. The various hanging buckets/devices after maintenance director staff E removed contained a build up of dark brown and black dried crusty growth. Maintenance director staff E replaced the various bucket/devices after each observation.

Contract certified mold inspector Z hired by the CAH on 1/9/13 at 2:30pm reported they suspected the growth and unidentified substances could be mold. Contract certified mold inspector Z stated mold needs water and a food source to grow and that the pipes had a gross build up of dust, which may be the mold ' s food source.

Infection control director staff G interviewed on 1/8/13 at 4:00pm reported they were aware of the various devices used by hospital maintenance staff and verified the practice did not meet accepted standards of practice for infection control. Infection control director staff G reported they identified dietary environmental concerns in their environmental rounds report and quality assurance program documentation. However the CAH had not taken action on the concerns.

Hospital infection control policy, " Environmental Rounds " revised on 11/12, reviewed on 1/9/13 directed staff to evaluate all departments every 6- months to identify areas in need of repair. Review of environmental round reports revealed two dietary evaluations on 12/12/11 and 10/29/12. Both reports lacked evidence of any areas in the dietary department in need of repair from water damage or noted areas, which required action to repair stains/growths of unknown origin.

Environmental supervisor staff F and infection control director staff G interviewed on 1/9/12 at 9:00am reported the hospital lacked evidence of documentation to identify the current environmental concerns in their dietary department.

Review of the hospital ' s quality assurance program lacked evidence the hospital staff identified, tracked and made corrective actions for the dietary environmental concerns.

The Critical Access Hospital (CAH) provided dietary services as a direct service for an average of 9 patients. The four maintenance staff members (staff E, F, and H) and dietary manager staff D failed to follow accepted standards of practice in the dietary department to maintain dietary equipment to ensure a safe and sanitary dietary department.

Findings include:

- Tour of the dietary department located in the hospital ' s basement on 1/8/13 at 8:15am with dietary manager staff D and environmental supervisor staff F, revealed the following areas in need of repair:

1. Dry storage area #1 contained three industrial stainless steel racks with boxed food and bagged pasta stored on the shelves. The ceiling above the food storage shelves had an " L " shaped raised and rough area of jagged white crystal like growth/stain hanging ½ inch from the ceiling which extended five feet from the right corner of the room on to the back wall, then two feet along the ceiling of the left wall.

2. Dry store area#2 contained four industrial stainless steel racks with boxed food and canned food on the shelves. Observation the back wall revealed a white plastic gutter (formed to make a holding tray) hanging from an 8 foot insulated white pipe. The plastic gutter had holes drilled in the sides with wires inserted to hold the gutter to an 8 foot white pipe. The pipe had a thick white insulation covering with dark fuzzy, round spots that extended the length of the pipe. Maintenance Manger staff E on 1/8/13 at 10:00am reported they placed the gutter under the pipe to catch condensation/moisture from the pipe.

3. Dietary chemical closet adjacent to #1 and #2 ' s storage areas contained a 2-gallon plastic bucket wired to a pipe that extended the length of the (50-foot hallway). The chemical closet also contained a 2-gallon ice cream container and 2-gallon hardware store bucket suspended from a pipe with wire. The bucket has a dry dark buildup covering the bottom of the container.

4. The hallway outside the hospital ' s public/staff dining room had a 2 foot by 2 foot ceiling tile with a 6-inch dark brown stain outlined by a raised fuzzy black substance that looked like mold.

5. The public/staff dining room ' s ceiling had two- 2 foot by 4 foot ceiling tiles with dark brown stains. Stain #1 measured 8 inches by 6 inches with a raised fuzzy black mold like substance. The second dark brown stain measured 4 inches in circumference.

6. The public/staff dining room had a 2-foot by 4-foot plastic vent tile with one-inch open squares. The vent had a red sheetrock mud tray suspended directly over a dining room table.

7. Storage area #3 was a 16-foot by 12-foot room used for miscellaneous storage (not food) and had a suspended ceiling with 4-foot by 2-foot tiles. The ceiling had two tiles with dark brown stains. Storage room #3 ' s ceiling had dark black spots of mold like substance, which extended the length of the wall.

8. The dietary manager ' s office exterior wall had a 3-foot by 2-foot window located below ground, with an exterior window well. The wall below the window had a 3 X 2-foot irregular half moon shaped area of bubbled wall surface. Pressure applied to the raised, bubbled area, created a loud audible crunchy sound.

Maintenance staff H at 1:00pm, and environmental supervisor staff F opened the surface of the bubbled wall to reveal a white fuzzy unknown substance. Environmental supervisor staff F indicated the areas were mold based, but would need to consult with an expert to obtain a final report.

Maintenance director staff E interviewed on 1/8/13 at 10:00am reported they had been employed by the hospital for the passed 20 years and were responsible for hanging the various buckets, sheetrock mud trays and made the white gutter tray. Maintenance director staff E stated the pipes in the basement have a condensation problem in the summer which causes the pipes to sweat. Maintenance director staff E stated the various devices (buckets and guttering) catch the sweat and drips from the pipes. The various hanging buckets/devices after maintenance director staff E removed contained a build up of dark brown and black dried crusty growth. Maintenance director staff E replaced the various bucket/devices after each observation.

Contract certified mold inspector Z hired by the CAH on 1/9/13 at 2:30pm reported they suspected the growth and unidentified substances could be mold. Contract certified mold inspector Z stated mold needs water and a food source to grow and that the pipes had a gross build up of dust, which may be the mold ' s food source.

Infection control director staff G interviewed on 1/8/13 at 4:00pm reported they were aware of the various devices used by hospital maintenance staff and verified the practice did not meet accepted standards of practice for infection control. Infection control director staff G reported they identified dietary environmental concerns in their environmental rounds report and quality assurance program documentation. However the CAH had not taken action on the concerns.

Hospital infection control policy, " Environmental Rounds " revised on 11/12, reviewed on 1/9/13 directed staff to evaluate all departments every 6- months to identify areas in need of repair. Review of environmental round reports revealed two dietary evaluations on 12/12/11 and 10/29/12. Both reports lacked evidence of any areas in the dietary department in need of repair from water damage or noted areas, which required action to repair stains/growths of unknown origin.

Environmental supervisor staff F and infection control director staff G interviewed on 1/9/12 at 9:00am reported the hospital lacked evidence of documentation to identify the current environmental concerns in their dietary department.

Review of the hospital ' s quality assurance program lacked evidence the hospital staff identified, tracked and made corrective actions for the dietary environmental concerns.

The Critical Access Hospital (CAH) reported they failed to complete an Annual Evaluation for the year ending 12/31/2011 and reported a census of 19 patients.

Based on Staff interview and policy review the CAH failed to complete an Annual Evaluation for the year ending 12/31/2011.

Findings include:

- Policy Review "Annual Evaluation", revealed, a plan to complete an annual program evaluation. The plan revealed, "The purpose of the evaluation is to determine whether:
1. The utilization of services was appropriate;
2. The established policies were followed
3. Changes are needed.
The evaluation is to be conducted by a committee consisting of one or more physicians, and at least one member who is not a member of the CAH staff.
The evaluation will be conducted within 60 days of the end of the fiscal year. The evaluation will be conducted as follows, and then presented to the Board of Trustees for approval."

- Administrative staff A interviewed on 1/9/13 at 6:30pm confirmed the CAH failed to conduct a Periodic Evaluation and Quality Assurance Review for the year 2011.

- The CAH failed to ensure the Periodic Evaluation and Quality Assurance Review for 2011 included the utilization of CAH services, and at least the number of patients served and the volume of services provided, see evidence at C0332.

- The CAH failed to review a representative sample of both active and closed clinical records in the Periodic Evaluation and Quality Assurance Review for 2011, see evidence at C0333.

- The CAH failed to review health care policies as part of the Annual Periodic Evaluation and Quality Assurance Review, see evidence at C0334.

- The CAH failed to determine through the Annual Periodic Evaluation and Quality Assurance Review whether the utilization of services was appropriate, the established policies were followed, and any changes were needed see evidence at C0335.

- The CAH failed to ensure they have an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and the treatment outcomes see evidence at C0336.

- The CAH failed to ensure all patient care services and other services affecting patient health and safety are evaluated as evidenced at C0337.

- The CAH failed to ensure Nosocomial infections and medication therapy is evaluated as evidenced at C0338.

- The CAH failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners ' , clinical nurse specialists, and physician assistants at the CAH are evaluated by a member of the CAH (Critical Access Hospital) staff, who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH see evidence at C0339.

- The CAH failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH is evaluated by: 1). a member of the network, 2). QIO or equivalent entity or 3). Other appropriate and qualified entity identified in the State rural health care plan see evidence at C0340.

- The CAH failed to consider the findings of the evaluations, including any findings or recommendations of the QIO, and takes corrective action if necessary in the Periodic Evaluation and Quality Assurance Review for 2011, see evidence at C0341.

- The CAH failed to take appropriate remedial action to address deficiencies found through the quality assurance program necessary in the Periodic Evaluation and Quality Assurance Review for 2011, see evidence at C0342.

- The CAH failed to document the outcome of all remedial action necessary from the Periodic Evaluation and Quality Assurance Review for 2011, see evidence at C0343.

The Critical Access Hospital reported a census of 19 patients.
Based on interview and document review the Critical Access Hospital (CAH) failed to conduct a periodic evaluation of its total program at least once a year.

Findings include:

- Staff D, interviewed on 1/9/13 at 6:45pm revealed the CAH failed to complete a Periodic Evaluation and Quality Assurance Review for the year ending 12/31/2011.

- Policy Review of "Annual Evaluation", on 1/10/13 at 9:00am revealed, "The purpose of the evaluation is to determine whether: the utilization of services was appropriate; the established policies were followed; and changes are needed. The evaluation is to be conducted by a committee consisting of one or more physicians, and at least on member who is not a member of the CAH staff. The evaluation will be conducted within 60 days of the end of the hospital fiscal year and then presented to the Board of Trustees for approval."