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Based on observation, facility record review, and staff interview, the facility failed to comply with the Life Safety Code requirements for the critical assess hospital, including 1 of 3 ancillary locations (sleep lab) that provided patient care services.

The findings were:

1. Building #1 Critical Access Hospital:
a. K-025, Based on observation and staff interview the facility failed to ensure 1 of 2 smoke barrier walls were smoke resistant.
b. K-029, Based on observation and staff interview the facility failed to ensure hazardous areas were separated from use areas in 1 of 3 smoke compartments.
c. K-038, Based on observation and staff interview the facility failed to ensure egress corridors were unobstructed in 1 of 3 smoke compartments.
d. K-051, Based on observation and staff interview the facility failed to ensure smoke detectors had proper spacing in 1 of 3 smoke compartments.
e. K-056, Based on observation and staff interview the facility failed to ensure 2 of 3 smoke compartments had complete sprinkler coverage.
f. K-062, Based on observation, record review and staff interview the facility failed to ensure sprinklers were provided with escutcheon rings, failed to ensure sprinklers were unobstructed in 1 of 3 smoke compartments. The facility also failed to ensure the sprinkler backflow preventer was tested annually and failed to ensure sprinkler pressure gauges were tested every five years.
g. K-144, Based on observation and staff interview the facility failed to ensure a manual emergency stop button was provided on 1 of 1 emergency generator.
h. K-147, Based on observation and staff interview the facility failed to ensure temporary electrical wiring did not replace permanent fixed wiring and failed to ensure outlets in wet locations had ground fault circuit interruption (GFCI) protection in 2 of 3 smoke compartments.

2. Building #3 Sleep Lab:
a. K-046, Based on record review and staff interview the facility failed to ensure emergency battery lights were tested during 12 of the past 12 months.
b. K-051, Based on record review and staff interview the facility failed to ensure the smoke detectors had been tested annually in 2 of the past 2 years.

Based on observation, policy review, and staff interview, the facility failed to ensure outdated or unusable drugs and/or supplies were not available for patient use. Random observations in various areas such as the emergency department, nursing station, and nursery had outdated/undated patient care supplies, and 1 of 2 anesthesia cart observations had outdated/undated medications. The findings were:

1. During the initial tour of the critical access hospital on 5/16/11 from 1:45 PM to 5:42 PM the following observations were found regarding outdated supplies that were available for patient use in various departments:
a. Tour of the emergency department revealed a treatment room with 3 of 5 expired iodine swabs. The swabs were dated as expired on December 2009. Interview at the time of finding with the director of nursing (DON) confirmed the finding. The DON stated the swabs were used to clean wounds. He stated central supply was to pull and discard supplies that were outdated.
b. Tour of the in-patient nursing unit showed it was a combined unit and provided all in-patient nursing care. Tour of the supply room showed 11 of 18 Benzoin Tincture individual packets dated with an expiration of August 2008. The DON confirmed the finding and acknowledged that they were available for patient use. In addition, the unit's patient care refrigerator contained six dietary supplements (brand name: "Mighty Shakes"). According to the manufacturer's use label, the shakes were good for 14 days from the thaw date. All were undated, and available for use. Interview with the DON revealed neither he nor the staff knew what date the shakes had been thawed and did not have a process to ensure discarding of the shakes as per the manufacturer's label. Interview with the dietary manager on 5/16/11 at 4:19 PM confirmed nursing staff were responsible for removing the shakes from freezer and labeling them with the thaw date.
c. Tour of the surgical department showed facial electrodes dated with an expiration of March 2011. Observation of the surgical scrub area revealed an pre-operational scrub soap, Avagard D Hand Sanitizer, with an expiration date of December 2010. Licensed practical nurse (LPN) #1 toured the area with the surveyor, and confirmed the findings. She stated outdated supplies were to be discarded or returned to central supply.
d. In addition to the above, observations of alcohol based hand sanitizer in the nursery on 5/17/11 at 7:19 AM revealed it had expired April 2006. Environmental service staff member #1 confirmed the finding. The staff member stated the sanitizer in this area was seldom changed, and added outdated supplies were send back to the supply company or discarded.

Review of the facility's policy titled, "Central Supply Inventory Control," revealed all areas were responsible for checking and ensuring supplies were not outdated. It further stated expired supplies were to be returned to materials management.

2. During the initial tour of the hospital surgical operating department on 5/16/11 at 4:27 PM, observation of the anesthesia cart in surgical room #2 revealed the following concerns with medications:
a. An open bottle of Anectine (a paralytic used for anesthesia) was open, but undated. Observation of the rubber stopper revealed what looked like a puncture mark. LPN #1 was asked whether the bottle had been opened and used. She confirmed it was open, and stated it looked as if it had been punctured. She stated open multiple dose vials were supposed to be labeled as to when they were opened. She added they were good for 30 days.
b. Observation of a second multiple dose vial showed it, too, was open, but dated 3/11/11. LPN #1 confirmed the date and discarded the vial.

Review of the facility's policy titled, "Multi Dose Medication Vials in Clinical Areas," directed staff to date, time, and initial multiple dose vials. It further instructed that the vial was considered expired in 28 days "...or the manufacturer's recommended expiration date (whichever comes first) and discard at time of expiration."

Based on observation, policy review, and staff interview, the facility failed to ensure it followed recognized dietary practices during random observations in the dietary department and nursing care unit. The facility census was 7. The findings were:

1. Observation on 5/16/11 at 3:45 PM of the nursing unit's patient care refrigerator showed it contained six dietary supplements (brand name, "Mighty Shakes"). According to the manufacturer's directions for use, the shakes were good for 14 days from the thaw date. All were undated, and available for use. Interview with the director of nursing revealed neither he nor the staff knew to date the shakes. He stated they did not have a process to ensure discarding of the shakes as per the labeling requirements. Interview with the dietary manager on 5/16/11 at 4:19 PM confirmed nursing staff were responsible for removing the shakes from the freezer and ensuring the thaw date was labeled. He confirmed the need for disposal of the shakes after the 14 day period.

2. Observation of the noon meal preparation on 5/17/11 from 11 AM to 12:15 PM revealed the following concerns related to the cleanliness of equipment used to prepare food:
a. During the initial tour of the kitchen on 5/17/11 at 11 AM the Hobart mixer shield was observed to have dried white flaky food residue spattered on the interior of the shield. A clean mixing bowl holding a wire whisk and other clean utensils was housed within the arms of the mixer. The mixer's shield surrounded the clean bowl and utensils. At 12:15 PM, the dietary manager was asked about the mixer's shield and when the mixer was last used. He stated he was unsure, and as he asked the other dietary staff, no one could confirm the last time the mixer was used. The manager stated it should have been cleaned, including the shield, after use. Review of the facility's policy titled, Infection Prevention in Dietary, instructed that equipment such as the mixer, "...shall be disassembled, cleaned, sanitized, dried and reassembled after each use."
b. Observation showed a center food preparation table. Above the table, hung a metal holding rack from which staff retrieved serving utensils and other items during food service. The observation also revealed that some staff were capable of reaching and grabbing utensils by the handle. During two random observations, two separate staff members were only able to reach the serving surfaces of the utensils. Dietary aide #3 grabbed a spoon by the serving surface using her bare hand. The aide then used the serving surface to mix a powder in a container of water. The dietary manager was asked at 12:15 PM about the purpose for the mixture. The manager confirmed it would be used for a rice dish. When asked about the observed practice, the manager stated the staff should be using the handles of utensils when removing them from the overhead rack.

Based on medical record review, review of the OPO (organ procurement organization) agreement, facility procedure review, and staff interview, the facility failed to provide organ donation options to family members for 1 or 4 medical record reviews (#22) that involved a death. The findings were:

Review of the medical record for patient #22 showed a facility form titled, "Record of Death," dated 5/8/11. The space for "Organ and Tissue Donation" was blank; nothing was filled out related to when the OPO was contacted, or whom at the OPO was contacted. The only documentation was under eligibility, which was checked "no." Further record review showed a check list which documented the OPO was not called due to "No per MD [medical doctor]". According to the facility's procedure for organ, tissue, and eye procurement, date of origin 3/2004, "Star Valley Medical Center staff will notify the OPO of every death or imminent death in the hospital." Review of the OPO "Organ Donation Cooperation Agreement" with the facility, showed it stated responsibilities of the hospital included notification to the OPO "...in a timely manner of every individual whose death is imminent..." so that OPO staff can "...determine eligibility for donation...". The agreement stated for unregistered donors, the facility would "...ensure that the family of each unregistered potential donor is informed of their opportunity to donate organs, tissues, or eyes, or to decline to donate." Review of the medical record with the director of nursing on 5/18/11 and interview at 11:40 AM confirmed the OPO had not been contacted, and confirmed the OPO should be contacted for every death or imminent death.