HospitalInspections.org

Based on staff interview, staff meeting minutes, and lack of documented evidence, the Critical Access Hospital failed to complete a facility wide Legionella risk assessment, as required. (Legionella is a bacteria that grows in water supplies, and can cause pneumonia and other infections, in vulnerable patient populations.)

The facility reported an annual acute care patient census of 78 according to the most recent annual program evaluation.

This failed practice has the potential to affect all patients being served at the hospital.

Findings include:

1. Interviews with the Director of Safety on 8-9-18 at 10:45 A.M. and with the Director of Maintenance on 8-10-18 at 11:15 A.M. revealed the facility had mapped the plumbing throughout the facility during a recent remodeling project, but both confirmed nothing more had been done with the information, as it related to Legionella contamination prevention.

2. Staff meeting minutes dated January 8, 2018 stated, "Legionella policy is in progress." The Director of Maintenance confirmed in this same interview, that no further action to develop policies had taken place. In addition, the Legionella risk assessment of the facility's water supply had not been conducted, nor had any engineering control strategies been implemented.

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the medical record contained a discharge order written by a physician for 2 of 5 discharged surgical patients (Patients 16 and 17). This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 1/1/18 to 7/1/18 was 59.

Findings are:

A. Review of Patient 16's medical record (8/8/18 at 3:00 PM) revealed the patient had a colonoscopy (procedure used to look in the large intestine to dectect potential abnormalities), upper endoscopy (a procedure used to look at the upper digestive track including the stomach, esophagus and the first part of the small intestine) and removal of a right arm mass under MAC (monitored anesthesia care). Review of the entire medical record revealed a lack of evidence of a physician's discharge order of the patient from the hospital.

-Review of Patient 17's medical record (8/8/18 at 3:15 PM) revealed the patient had right shoulder arthroscopy (interior of a joint inspected and/or operated on) under general anesthesia. Review of the entire medical record revealed a lack of evidence of a physician's discharge order of the patient from the hospital.

B. Interview with the Director of Nursing (8/10/18 at 10:00 AM) confirmed the above medical records lacked the evidence of a physician's discharge order of the patient from the hospital.

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 2 of 5 surgical patients (Patients 17 and 18). This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries from 1/1/18 to 7/1/18 was 59.

Findings are:

A. Review of Patient 17's medical record (8/8/18 at 3:15 PM) revealed the patient had right shoulder arthroscopy (interior of a joint inspected and/or operated on). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (8:22 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 18's medical record (8/8/18 at 3:30 PM) revealed the patient had right shoulder arthroscopy. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (11:52 AM) to evaluate the risk of the procedure to be performed.

B. Interview with the Director of Nursing (8/10/18 at 10:15 AM) confirmed the above medical records lacked evidence of patient examinations completed by the physicians immediately before surgery to evaluate the risk of the procedure to be performed.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure that swing bed patient records included a recapitulation (a concise summary) of the swing bed stay for 5 of 5 swing bed patients (Patients 19, 20, 21, 22 and 23). This had the potential to affect all discharged swing bed patients. Total swing bed admits from 1/1/18 to 7/1/18 was 37.

Findings are:

A. A review of Patient 19's entire medical record (8/9/18 at 9:50 AM) lacked evidence of a recapitulation of the patient's swing bed stay from 2/1/18-3/2/18.

-Review of Patient 20's entire medical record (8/9/18 at 10:05 AM) lacked evidence of a recapitulation of the patient's swing bed stay from 3/13/18-3/19/18.

-Review of Patient 21's entire medical record (8/9/18 at 10:15 AM) lacked evidence of a recapitulation of the patient's swing bed stay from 4/6/18-4/23/18.

-Review of Patient 22's entire medical record (8/9/18 at 10:30 AM) lacked evidence of a recapitulation of the patient's swing bed stay from 5/6/18-5/17/18.

-Review of Patient 23's entire medical record (8/9/18 at 10:45 AM) lacked evidence of a recapitulation of the patient's swing bed stay from 6/1/18-6/5/18.

B. Interview with the Director of Nursing (8/10/18 at 10:10 AM) confirmed the above medical records lacked evidence of the swing bed recapitulations stating "I didn't know they had to be done."